Document of The World Bank Report No; 18342-BR PROJECT APPRAISAL DOCUMENT ONA PROPOSED LOAN IN THE AMOUNT OF US$100 MILLION EQUIVALENT TO THE FEDERATIVE REPUBLIC OF BRAZIL FOR A DISEASE SURVEILLANCE AND CONTROL PROJECT (VIGISUS) AUGUST 6, 1998 Human Development Sector Management Unit Latin America and the Caribbean Region CURRENCY EQUIVALENTS (Exchange Rate Effective March 31, 1998) Currency Unit = Real Real 0.91 = US$1.00 US$1 =1.1 Real FISCAL YEAR ABBREVIATIONS AND ACRONYMS APL Adaptable Program Lending CEME Central de Medicamentos - Central Pharmaceutical Agency CONASEMS Conselho Nacional de Secretarios Municipais de Saude CONASS Conselho Nacional de Secretarios de Saude CNS Conselho Nacional da Sailde - National Health Council FUNAI Fundacao Nacional do Indio - National Indian Foundation GDP Gross Domestic Product FNS Fundacao Nacional da Saude - National Health Foundation ICR Implementation Completion Report MOH Ministry of Health NGO Non-government Organization NSS National Surveillance System PCU Project Coordinating Unit RNIS Rede Nacional de Informacoes em Saude - National Health Information Network SUS Sistema Unico de Saude - Unified Health System Vice President: Shahid Javed Burki Country Director: Gobind T. Nankani Sector Director: Xavier Coll Team Leader: Jean-Jacques de St. Antoine Brazil Disease Surveillance and Control Project (VIGISUS) CONTENTS A. Project Development Objective .......................................................2 1. Project development objective and key performance indicators ................. ...............2 B. Strategic Context .......................................................3 1. Sector-related CAS goal supported by the project ................................................. 3 2. Main sector issues and Government strategy .................................................3 3. Sector issues to be addressed by the project and strategic choices .............................4 C. Project Description Summary .......................................................6 1. Project components .................................................6 2. Key policy and institutional reforms supported by the project ..................................7 3. Benefits and target population .................................................7 4. Institutional and implementation arrangements ................................................. 7 D. Project Rationale .......................................................8 1. Project alternatives considered and reasons for rejection ...........................................8 2. Major related projects financed by the Bank and/or other development agencies .................................................9 3. Lessons learned and reflected in proposed project design ..........................................9 4. Indications of borrower commitment and ownership ............................................... 10 5. Value added of Bank support in this project ................................................ 11 E. Summary Project Analyses ...................................................... 11 1. Economic ...................................................... 11 2. Financial ...................................................... 11 3. Technical ...................................................... 11 4. Institutional ...................................................... 11 5. Social ...................................................... 11 6. Environmental assessment ...................................................... 12 7. Participatory approach ...................................................... 13 F. Sustainability and Risks ...................................................... 13 1. Sustainability ................................................ 13 2. Critical risks ................................................ 14 3. Possible controversial aspects ................................................ 14 G. Main Loan Conditions ........................ 14 1. Effectiveness conditions ........................ 14 2. Other ........................ 14 H. Readiness for Implementation ........................ 14 L Compliance with Bank Policies ........................ 15 Annexes Annex 1 a. Project Design Summary Annex lb. Detailed Project Description Annex 2. Detailed Project Description and Project Implementation Plan Annex 3. Estimated Project Cost Annex 4. Financial Summary Annex 5. Procurement and Disbursement Arrangements Annex 6 Economic Analysis Annex 7. Control of Endemic Diseases in the Amazon Region Annex 8. Organization and Legal Framework of the FNS Annex 9. The Brazilian Epidemiological Surveillance System Annex 10. The System of Public Health Laboratories Annex 11. The Data Management Telecommunications System Annex 12. Training Program Annex 13. Project Management and Operational Manual Annex 14. Indigenous Health Development Annex 15. Project Processing Budget and Schedule Annex 16. Documents in the Project File Annex 17. Letter from Government Annex 18. Statement of Bank and IFC Portfolio Annex 19. Brazil at a Glance Federative Republic of Brazil Disease Surveillance and Control Project (VIGISUS) Project Appraisal Document Latin America and the Caribbean Regional Office Human Development Sector Management Unit Date: August 6, 1998 Team Leader: Jean-Jacques de St. Antoine Country Director: Gobind T. Nankani Sector Manager/Director: Xavier Coll Project ID: 43874 Sector: Health, Nutrition, & Program Objective Category: Health Improvement Pop. Lending Instrument: Adaptable Program Loan Program of Targeted [X] Yes [ ] No Intervention: Progrm incingDa a |:..__:_-._____ Sores sofFinancing(1$illio} Total Cost Government Bank Total First APL (1999-2002) 200 100 100 200 Second APL (2003-2004) 200 100 100 200 Third APL (2005-2006) 200 100 100 200 Program Cost 600 300 300 600 Project Financing Data [X] Loan [] Credit [ ] Guarantee [] Other [Specify] For Loans/Credits/Others: Amount (US$): 100 million Proposed terms: [x] Multicurrency [] Single currency, US Dollar Grace period (years): 3 [] Standard Variable [ Fixed [] LIBOR-based Years to maturity: 12-15 Commitment fee: 0.25%.% Financing plan (US$m): Source Local Foreign Total Government 100 - 100 IBRD 52 48 100 Total 152 48 200 Borrower: Federative Republic of Brazil Guarantor: N/A Responsible agency: Ministry of Health (MOH) through Fundacao Nacional da Sauide (FNS) Estimated disbursements (Bank FY/US$m): 1999 2000 2001 2002 Annual 20 35 35 10 Cumulative 20 55 90 100 Expected effectiveness date: January 1999 Expected closing date: December 31, 2002 2 A: Project Development Objective 1. Project development objective and key performance indicators (see Annex 1): The VIGISUS program seeks to improve and strengthen the national disease surveillance and control system' (NSS) to contribute to reduce mortality and morbidity resulting from communicable diseases. The program will consist in three projects phased over eight years that will seek to strengthen the surveillance system nationally through: (i) the improvement of the data management telecommunications system; (ii) the rehabilitation of the laboratory network; and (iii) the training of staff. In addition, the program would support disease prevention and control in the Amazon Region2 and for indigenous populations. The APL instrument is used: (i) to put the overall program in a broad medium-tern perspective; (ii) because the Government recognizes the difficulty of designing a comprehensive project and prefers to divide the problem into more realistically implementable phases; and (iii) the APL instrument allows for corrections and redesign at the end of each phase, based upon the practical experience of that phase. Sector Analysis and Vision. A description of some of the main endemic diseases is presented in Annex 7. An overview of the Brazilian epidemiological surveillance system is presented in Annex 9. A vision of the disease surveillance system as it is today and as it will be in 10 years is presented in Annex lb. An analysis of the organization, legal framework and decentralization process of the FNS is presented in Annex 8. The system of public health laboratories is discussed in Annex 10. The data management telecommunications system is presented in Annex 11. Key performance indicators of progress towards program objectives will be measured through a monitoring and evaluation system. The complete set of monitoring indicators for the program is presented in Annex lb. Passage from APL I to APL II would be determined based on the analysis by the Borrower and the Bank of performance of VIGISUS compared to the following selected indicators: (i) at least 50 candidates would have been trained under the "Basic Principles of Outbreak Investigation" course; (ii) at least 200 superior-level and 100 mid-level staff would have been trained in laboratory biosafety; (iii) 9 national reference laboratories would have been rehabilitated and equipped; (iv) data and coding standards for the NSS would have been properly defined; (v) the new notifiable diseases reporting system (SINAN) would be fully operational in at least 20 national or macroregional public health laboratories (i.e. that these laboratories have each established a system to monitor the timeliness of reporting and compliance with targets set by the FNS for the key notifiable diseases); (vi) 300 indigenous community health agents would have been trained; and (vii)the number of cases of tuberculosis cured in the Amazon Region would have increased by at least 10 percent. Passage from APL II to APL III would use a set of similar indicators which would be used to establish that the National Surveillance System has been established including: (i) an adequate information system in all states and 300 municipalities; and (ii) public health laboratories adequately staffed, and properly equipped in all states. A national surveillance system is a system that: (i) collects the basic information necessary at the municipal and state levels for the control of diseases, epidemics, and environmental health hazards; and (ii) proposes measures to monitor and control the development of epidemics. The basic information collected and published consists of: (i) incidence of disease by regions, age, sex, and ethnic background; (ii) mortality; and (iii) epidemiological and environmental studies and research. Such a system requires an infrastructure consisting of: (i) a network of laboratories that undertake exams to confirm clinical diagnoses and establish the existence of an epidemic or environmental health hazards; (ii) a data management telecommunications system; and (iii) properly trained management and technical staff. The system is closely linked to the health facilities network in charge of controlling diseases at the community level either through vaccination, other preventive measures, or curative treatment. One of the most sophisticated epidemiological surveillance systems is the Center for Disease Control and Prevention in the U.S. The Brazilian disease surveillance has been in existence for 20 years. It is extensive and has a positive track record. However, it has become bureaucratic and inefficient. 2 The Amazon region comprises the following 9 states: Acre, Amapa, Amazonas, MaranhAo (western part), Mato Grosso, ParA, Rondonia, Roraima, and Tocantins. 3 B: Strategic Context 1. Sector-related Country Assistance Strategy (GAS) goal supported by the project (see Annex 1): CAS document number: 16582-BR. Date of latest CAS discussion: CAS update June 2, 1998 The proposed project would directly support the CAS' objectives of helping the government improve the management, financial viability, and quality of the public health care system that serves the poor, and fulfill its role as the source of public goods. It will encourage investments in underserved groups by putting emphasis on the control of communicable diseases that disproportionately affect vulnerable groups in the Amazon region and indigenous populations. By helping to decentralize the FNS, the project will help the federal government continue to make the transition from health care provider to health care regulator, and strengthen health system management capacity at all levels of government. 2. Main sector issues and Government strategy: The main sector issues are: (i) financing of the system; (ii) deterioration of health care facilities; (iii) quality of care; (iv) unfinished agenda in addressing health issues; and (v) lingering centralization in some parts of the system. (i) Financing. The level of public expenditures (3% of GDP in 1994) was insufficient to pay for a comprehensive health benefit package for the whole population. This led to rationing and disadvantaged the poor who are less successful in breaking waiting lists. This has to be read against the continuing municipalization of the health system that has occasioned increased budget transfers during recent years from the state to the municipal level. The managerial and financial capacity of the municipalities is mixed and some of them are unable to provide quality health services. The low population density compounds the access problem in some parts of the country such as the Amazon Region. (ii) Deterioration of health facilities. Chronic under-financing has led to a deterioration of facilities, shortages in essential inputs, and poor remuneration of professionals, leading to inefficiency, poor quality of care, and fraud. A number of ongoing projects purport to address these issues. The Bank-financed REFORSUS project aims at correcting the dearth of equipment of public providers (hospitals, health posts, emergency units, specialized ambulatory units etc.). Private providers also benefit from a line of credit agreed upon between the Brazilian Federation of Hospitals, the Bank for Economic and Social development (BNDES), and the Ministry of Health. Finally the provider payment system has recently been restructured to benefit the areas of maternal and child health, emergency care, intensive therapy, home care, and care for patients with chronic and degenerative diseases. (iii) Quality of care. With few exceptions, public sector and many philanthropic hospitals are poorly managed. The hospital fatality rate that has been increasing since 1991 to a decade-high 2.4 percent in 1995, could be indicative of an inadequate quality of care'. (iv) Health issues. Health conditions have improved over the past 20 years. From 1970 to 1993, life expectancy grew from 61 to 67 years and infant mortality declined from 95 to 42 deaths per 1,000 births. The decline of child mortality and fertility is creating new demands on the health care system, such as the aging of the population, and is bringing to the fore non-communicable diseases such as chronic heart and pulmonary diseases and cancer. Injuries from violence and traffic accidents have growing importance, causing more years of potential life loss than any other single cause except cancer. Yet communicable diseases remain a major risk for the poor and the young, especially those living in the North and Northeast where infectious and parasitic A thorough analysis would require looking at the trends in hospital fatality rates for specific age groups and by cause of death. 4 diseases rank third among the causes of reported deaths. The country is still experiencing recurrent epidemics of diseases such as malaria, dengue, tuberculosis, kalazar, and AIDS. (v) Lingering centralization. Although the Unified Health System (SUS) has been largely decentralized, two areas remained centralized up to recently: the FNS4 and the Central Pharmaceutical Agency (CEME), a federal agency for the procurement of drugs. The recent closing of CEME confirms the intention of the current administration to proceed with the institutional restructuring process and transfer activities towards the states and municipalities. Government Strategy. Issues (i) to (iii) are being addressed under the REFORSUS project (Loan 4047-BR). In 1995, provider reimbursement rates were increased by 25 percent. Also, with Bank assistance, the government prepared a list of most cost-effective interventions to be fully reimbursed such as to match the system's benefits with resource constraints. It introduced legislation to allow cost recovery of care provided to privately-insured patients receiving care under the SUS. Global budgets started to be used for states and municipalities to improve control over expenditures. The program to consolidate the SUS, which was initiated in 1995, is expected to last into the next decade. It is based on a decentralized management model according to which the states and municipalities will assume autonomy and will have the responsibility to implement health policies and programs. Under this organization plan, the MOH will ensure that the supply of services does not become fragmented and scattered, and that the regional, hierarchical system is operating smoothly. Improved resource allocation would result in better equity in access to services and improved quality. The MOH will try to give priority and raise provider payment levels for all health care services and activities that are recognized to be most cost-effective. As a result, in the course of the next ten years, the supply profile would be redesigned, with an increase in effective and cost-effective services, to the detriment of those that have not proven to be so. Activities under the REFORSUS project will make it possible to halt the steady deterioration of the physical infrastructure and correct the critical shortcomings in management, while reducing fraud and guaranteeing acceptable quality standards for health care services. In the short and medium term, there should be stable and regular sources of a viable amount of funding for the SUS. Issues (iv) to (vi) would be addressed largely under the proposed project, under the on-going AIDS Control project (Loan 3659-BR) and under a Second AIDS Control project, negotiated in July 1998. The issue of injury control is high on the Government's agenda and sector work is currently being undertaken on that problem. The issue of non-communicable diseases will be addressed through policy dialogue with the government. 3. Sector issues to be addressed by the project and strategic choices: (i) Health issues. The project would help improve the surveillance and control of communicable and emerging diseases by strengthening the national epidemiological and environmental surveillance system and would finance surveillance and disease control subprojects presented by states and municipalities in the Amazon region and by indigenous populations. 4The FNS is part of the Ministry of Health (MOH). Its organization, legal framework, and decentralization process are presented in Annex 8. 5 (ii) Lack of coverage of the poor. The disease control part of the project would focus on the nine states of the Amazon region and will benefit mostly the poor who are affected disproportionately by communicable diseases. Indigenous populations throughout the whole country would also receive special attention. (iii) Centralization. The project would help the MOH decentralize the FNS and provide broader responsibilities to states and municipalities. Thus the FNS would be transformed from a federal vertical program organization toward a mostly regulatory, monitoring, and technical assistance agency. For the first time, states, municipalities, and philanthropic health care providers would have the opportunity to present their own surveillance and control subprojects to be financed under the project in a decentralized manner. The capacity of states and municipalities to undertake disease surveillance, and control programs would be strengthened. Additional assistance would be provided to weaker states and municipalities. (iv) Other issues. Health care financing for disease surveillance and control would be decentralized. As more states and municipalities would take an increasing share of surveillance and control functions previously undertaken by the FNS, they would receive financing to that effect under the SUS. Payment by procedures, i.e. specific tasks, will replace broader contracts. Decentralized financing, together with decentralized management and technical assistance, is expected to improve the quality of care as resource allocation would be better adapted to local needs. 6 C: Project Description Summary (see Annexes 2 and 3 for a detailed description and cost breakdown and Annex 4 for the financing plan) 1. Project components: Component I. Strengthening of National Surveillance Institution- 141 71.5% System. This component, to be implemented nationally, building, will: (i) improve the data management physical telecommunications system by providing microcomputers, printers, and telephone lines to municipalities; (ii) rehabilitate, expand, and equip the laboratory network (about 100 level-I laboratories; 12 level-II border laboratories; 12 level-III laboratories; and about 50 zoonoses centers); (v) train municipal, state, and central FNS staff in epidemiology, laboratory reporting, laboratory biosafety, environmental surveillance, and management (the detailed training program is presented in Annex 12); (vi) support studies and research in epidemiological and environmental surveillance; and (vii) provide technical assistance for project implementation. Component II. Strengthening of Disease Control in 44 22% Selected Areas. This component will finance: (i) disease surveillance and control in the nine states of the Amazon Region focusing on 329 municipalities (out of a total of Physical, 801) where the incidence of communicable diseases is institution the highest; and (ii) improvement in indigenous health in building all states with a significant indigenous population. The Amazon Region subcomponent will finance: (i) infrastructure rehabilitation; (ii) laboratory equipment; (iii) transport equipment (vehicles and boats); (iv) training of community health agents and municipalities' staff in communicable disease prevention and control; and (iv) drugs (e.g. antimalarial drugs, diagnosis reagents, etc.). The indigenous subcomponent, to be implemented nationally, will finance: (i) rehabilitation and equipment of health centers, health posts, environmental, and other health facilities; (ii) equipment; (iii) training of indigenous health agents; and (iv) technical assistance. III. Project Administration. This component would Project 15 7.5% help finance the administrative and operating costs of the management Project Coordinating Unit (PCU) over a 3-year period. This includes: (i) financing of PCU consultants; (ii) travel; (iii) training; (iv) equipment; and (v) other administrative expenses (materials etc.). Total 200 100% 7 2. Key policy and institutional reforms supported by the project: The key policy and institutional reform sought under the project is the reorganization and decentralization of the ENS which involves: (i) the internal reorganization of the institution; (ii) the transfer of physical assets to states and municipalities; (iii) a reduction of staff on FNS payroll; and (iv) further decentralization of financing for disease surveillance and control. 3. Benefits and target population: The project would benefit the whole Brazilian population. It would increase the effectiveness and efficiency of the health sector by: (i) creating a sound disease surveillance system; (ii) improving the control of diseases, thus reducing the probability of transmission and of the occurrence or spread of epidemics; (iii) reinforcing the decentralization process by improving problem-solving capacity at the federal, state, and municipal levels; (iv) improving the infrastructure and equipment of the laboratory system; and (v) providing training to management and technical teams at the three government levels. The second component will benefit the poor significantly, as they are affected disproportionately by communicable diseases. The implementation of the surveillance system would allow to identify high-risk groups, and target disease control interventions to the most vulnerable ones. Already-knowvn high-risk groups such as those living in the Amazon and other frontier populations would receive a strong focus since the beginning of the project. From the institutional point of view, states, municipalities, and non-profit health care providers would be important beneficiaries as their capacity to prepare, evaluate, and implement subprojects would be strengthened under the project. 4. Institutional and implementation arrangements: Implementation period: 3.5 years (APL I) Executing agencies: The project would be coordinated by the FNS through a PCU. The PCU would: (i) ensure the project's management and coordinate project implementation, including maintaining project records and preparing regular implementation reports; (ii) provide technical assistance to states and municipal subproject units; and (iii) monitor and supervise the implementation of subprojects. The PCU has been created, staffed, and is operational. A detailed description of the project management is presented in Annex 13. Operational Manual. The Operational Manual, prepared by the ENS, defines criteria with which subprojects would need to comply, including notably the use of proper health protocols, the type of infrastructure required, the adequacy of staffing or training plan, the availability of recurrent costs to ensure sustainability, and the measures to be taken to ensure that the environment will not be negatively affected. The main contents of the Operational Manual are presented in Annex 13. Accounting, financial reporting and financial arrangements. The financial administration of the project (including contracting and disbursement) would be coordinated by the PCU, which would disburse funds directly to states or municipalities or through a third party. To facilitate disbursements, a Special Account with a 90-day advance would be established. The project would be audited annually by an independent auditing agency acceptable to the Bank. Monitoring and Evaluation Arrangements. The PCU would be responsible for project monitoring and analysis. It would use performance indicators, including outcome, output, process and input indicators detailed in Annex lb. The technical supervision of the subprojects would be carried out by states and municipalities supported, when necessary, by consultants. Progress reports, including monitoring indicators, would be sent by the PCU to the Bank every six months. D: Project Rationale 1. Project alternatives considered and reasons for rejection: Flexible Project Design. One alternative design would have been a 100 percent top-down, fully-detailed blueprint design. However, in the context of a large country like Brazil this has proved to be too rigid. A small group of staff at the center cannot pretend to know the needs of 27 states and more than 5000 municipalities. Detailed surveys would provide more information, but would be cumbersome, time-consuming, and would become quickly out of date. On the other hand, as this is a national surveillance system for which there is need for an overall concept for the information and laboratory network and basic norms to be followed by the staff in implementing the system. As a result, the project is partly pre-designed and partly implemented on the basis of subprojects presented by decentralized institutions. For the pre-designed part, this means that an analysis of needs, a survey of existing infrastructure and equipment, and a skills analysis of the disease surveillance and control staff, have led to a detailed definition of a core group of activities that needed to be designed in a planned fashion so as to ensure a coherent and coordinated effort to strengthen the data management telecommunications system, the network of laboratories, and upgrade the skills of the staff. This represents about 40 percent of the project cost. The rest of the project (60 percent of the project cost) will come under the form of subprojects to be presented by municipalities, states, NGOs, and other institutions. These subprojects would represent the needs of these municipalities etc. to complement the pre-designed part. To ensure that they fit within the overall framework, comply with the norms of the FNS, and are properly targeted, subprojects will be prepared and evaluated according to eligibility and evaluation criteria included in the Operational Manual. The breakdown between pre-designed activities and subprojects is presented in Annex 2. * Size. The second alternative would have been either a larger or a smaller project. A larger project would have involved supporting disease control in all states. That option would have been ambitious and would stretch the existing institutional capacity. A smaller project would only be limited to installing a surveillance system in the Amazon (the same area where disease control improvement would be focused under the project). While feasible, it would not take advantage of the initial fixed costs and economies of scale involved in the development of a surveillance system. The alternative chosen (i.e. a surveillance system at the national level, disease control in the Amazon region, and indigenous health nationally) represents a compromise that is considered feasible and in line with the present institutional capacity of the FNS, states, and municipalities, and that to be developed under the project. The choice of the Amazon region for disease control makes sense because it is the area in Brazil with the highest incidence of communicable diseases. 9 2. Major related projectsfinanced by the Bank and/or other development agencies (completed, ongoing and planned): Sector Issue L ---t E--La S si Implementation Development Progress (IP) Objective (DO) AIDS prevention AIDS Control HS S and control (Loan 3659-BR) Health sector Health Sector S S financing, Reform improvement of (REFORSUS) infrastructure and (Loan 4047-BR) management Improvement of Northeast Basic S S basic health care Health Services services II (Loan 3135- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _B R )_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Supervision Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory) 3. Lessons learned and reflected in the project design: The project would benefit from the experience of recent health projects in Brazil, namely the Amazon Basin Malaria Control project, the Northeast Endemic Disease Control project, the Northeast Basic Health Services I and II projects, the Health Sector Reform project (REFORSUS), and the AIDS Control project. The Implementation Completion Reports (ICRs) for the Amazon Basin Malaria and Northeast Endemic Disease Control projects provide valuable advice for the present operation. These two loans totaled US$208 million and were disbursed over a 6-7 year period. They started with a slow implementation pace, but finished strongly. In their analysis regarding future operations, the ICRs note that environmental and demographic conditions in the Amazon Basin and in the Northeast, i.e. poor household and environmental sanitary conditions and the strong immigration to and within these regions, will continue to favor the occurrence of malaria and other communicable diseases. State and municipal capacity to control communicable diseases has greatly improved, but is still weak in many places. Some states and municipalities, such as Amazonas, Northern Mato Grosso, and Pari (in the Amazon region), and Minas Gerais, Bahia, Pernambuco, and Ceara (in the Northeast) are now able to take more responsibility for communicable disease control than before, but other states such as Amapa, Roraima, and Alagoas will continue to need strong assistance from the federal level, i.e. from the FNS. Bank support for a follow-up disease control operation is thus justifiable. The ICRs suggest that such an operation should: (i) have broader objectives, i.e. include the control of malaria as well as other communicable diseases such as dengue; (ii) include demand-driven components to finance state and municipal communicable disease control subprojects; and (iii) have an institutional development component to strengthen the capacity of weaker states and municipalities, and assist in restructuring the FNS. More broadly, the ICRs note that conditions for future operations in the health sector are good. Political, economic, institutional, and managerial conditions have improved significantly, and the country is much more capable of carrying out social programs with objectivity and efficiency. With better-trained human resources and improved management capability achieved through these and other Bank-financed projects, future health operations in Brazil should be implemented with fewer obstacles and in less time. The ICRs recommend that 10 future operations in the health sector, including those in the area of communicable disease control, include efforts toward the decentralization and municipalization of health care through the SUS. Other lessons learned are: (i) Application of proper disease control models. Under the Amazon Basin Malaria Control project, the traditional approach of eradicating mosquitoes was replaced with a strategy that emphasized early diagnosis and immediate treatment of the disease, coupled with targeting insecticides solely to transmission areas. Technical lessons were also learned for Chagas' disease, schistosomiosis, and leishmaniosis. (ii) Sustainability. Under the Amazon Basin Malaria and Northeast Endemic Disease Control projects, a new financing system started to be introduced through which the MOH entered into agreements with municipalities for the financing of communicable disease surveillance and control activities. The recognition of the need for specific financing for these activities and the renewal of contracts through the years started to establish the sustainability of these activities. (iii) Government commitment. In the past, various changes in Ministers and in project managers have often resulted in decreased commitment by the Brazilian authorities to project objectives. These problems seem to have been partially reduced lately with the successful implementation of an economic reform program that has increased the political and financial stability in the country. Since 1994, most Bank-financed health projects have had strong Government commitment and fairly stable project management. The present APL design will help bridge changes in administration by allowing adaptations in specific parts of the program. (iv) Inadequate project design. Several projects in Brazil have been preceded by poor institutional analysis. As a result, the design of many projects had to be reviewed during execution, causing delays in implementation and additional costs. The VIGISUS project, besides being preceded by broad institutional discussions and support, includes a demand-driven fund-like component, whereby funds are allocated to different geographical areas on the basis of agreed criteria, and subprojects are presented by the beneficiaries, ensuring their ownership. This demand-driven approach will facilitate the implementation of the project, as has already been demonstrated under the REFORSUS and AIDS Control projects which have a similar design. (v) Poor project implementation arrangements. In the past, project implementation has been affected by: (a) cumbersome MOH procedures; (b) the large number of steps for financial transactions between the Bank and the ultimate contractor; (c) improper knowledge by the MOH of Bank procurement guidelines; and (d) inadequate supervision and technical assistance to states. During the recent years, experience in the implementation of Bank projects has shown the critical path for project implementation. Use of proper budget codes for the programming of counterpart funds, flexible modification of state financing agreements, and significant improvement in knowledge and application of Bank procurement procedures are some of the most salient factors of progress in project implementation. The design of Project Coordinating Units has also significantly improved. The VIGISUS PCU have staff with well-defined technical, appraisal, and supervision functions that would support the implementation of the project by FNS staff. It would help weaker states and municipalities in subproject preparation, evaluation, and supervision. The manager who was instrumental in the turnaround of the Amazon Basin Malaria and Northeast Endemic Disease Control projects has been appointed Director of the VIGISUS' PCU. (vi) Training and other forms of institutional strengthening should be implemented at least at the same pace as investments in civil works and equipment. This is contemplated in the project design. 4. Indications of borrower commitment and ownership: The main indications are: (i) the VIGISUS project is included as a Government priority in the President's 1998 Message to Congress: (ii) the federal government has taken the lead in project identification, preparation, and appraisal; (iii) states and municipalities are being consulted through their representatives in the National Health 11 Council (CNS), the National Health Council of State Health Secretaries (CONASS), and the National Health Council of Municipal Health Secretaries (CONASEMS); (iv) counterpart funds for the project have already been included in the 1998 MOH budget; and (v) an experienced and well-recognized manager has been appointed Director of the PCU. 5. Value added of Bank support in this project: The Bank is the largest financier of communicable disease projects in the world and has financed successful projects in the Northeast of Brazil and in the Amazon, in the area of communicable diseases including malaria, Chagas, schistosomiosis and leishmaniosis. The Bank was pioneer in financing health care for indigenous people in the Amazon, i.e. for the Yanomami. Finally, the Bank has developed valuable experience in executing projects through states, municipalities, and NGOs in Brazil through the Northeast Basic Health Services I and II and the AIDS Control projects. E: Summary Project Analysis (for detailed analysis, see annexes 6-11) 1. Economic. Cost-benefit analysis was undertaken by: (i) estimating the benefits from potential life-years saved through better disease surveillance; (ii) estimating the benefits from reduced morbidity and the cost of hospital-days saved by reducing communicable disease incidence; and (iii) comparing benefits with investment and incremental recurrent costs. The project shows an internal economic rate of return of 36 percent. The project is expected to be sustainable. In a high scenario, incremental recurrent costs would represent 10 percent of the capital costs incurred in any particular year. Assuming that the health budget would remain constant as a percentage of total public spending, the resources available to the MOH would be more than sufficient to cover the additional recurrent costs generated by the project. Sensitivity analysis shows that the project would be sustainable even if incremental recurrent costs represented 25 percent of capital costs. The activities proposed under this project are the constitutional obligation of the federal government that will transfer part of the funds to states and municipalities. The project is not expected to increase the financial burden on the treasuries of states and municipalities as the federal level is expected to continue to transfer the funds to states and municipalities as has been the case under previous Bank-financed communicable diseases projects and under recent practice. The recently-introduced Piso da Aten9ao Basica (PAB) provides a formal mechanism for the transfer of funds for basic services and disease surveillance activities demonstrates the high priority that the Government gives to these activities. The transfers to municipalities and states for epidemiological and environmental surveillance, the primary source of funds for VIGISUS-related activities, were expected to be set at R$42 million for 1998. The detailed economic analysis is presented in Annex 6. 2. Financial. The financial management capacity of the FNS has been reviewed and found satisfactory. The FNS has already demonstrated its capacity in that area through the implementation of two Bank-financed projects. 3. TechnicaL The appropriateness of: (i) the design of the national surveillance system; and (ii) the protocols used to prevent and cure the principal communicable diseases were analyzed and found to be satisfactory. Details are provided in Annexes 7, 9, 10, and 11. 4. Institutional. Significant project management capacity has been developed during the Amazon Basin Malaria and Northeast Endemic Disease Control projects, and the Northeast Basic Health Services I and II. Project management capacity is strong at the federal level and variable at the state and municipal levels. Technical assistance will be provided to strengthen the capacity of states and municipalities to prepare, appraise, and supervise subprojects. In addition, during the initial months of project implementation, extensive technical assistance on procurement will be provided. 5. Social. Since the project will concentrate on institutional strengthening to develop and consolidate a surveillance system for health in a decentralized environment, the major stakeholders of the project have been 12 identified as the national, state, and municipal governments, health care NGOs, universities, and research institutions, and the private sector. Since the project's sustainability will depend on the involvement and commitment of all these stakeholders, the FNS has been consulting with them and will continue to do so during the coming months to explain the targeting principles and the eligibility and appraisal criteria for the preparation and appraisal of subprojects. Indigenous Peoples Issues. Upon the Government's request, a specific subcomponent was included to address indigenous groups. For the first time, a Bank-financed project will cover indigenous groups nationwide, with the objectives of strengthening the institutional network involved in providing disease control and health care, providing training to indigenous community health agents, and supporting specific health care actions. There are 204 indigenous ethnic groups in Brazil, totaling about 300,000. They are present in 24 of 27 Brazilian states, but the majority of them live in the Amazon region. According to the Constitutional Law, the federal government has the mandate to protect this population, safeguard their cultural and social organization, and guarantee their access to land and productive assets. Since 1991, the FNS and the Fundacdo Nacional do Indio - FUNAI (National Indian Foundation) share the responsibility for providing health care to the indigenous peoples. In principle, the FNS focuses on prevention and control of diseases, and FUNAI focuses on primary care and treatment. There is a visible effort from both to work collaboratively. An Indigenous Peoples Development Plan has been developed. It addresses: (i) the demographic and geographical distribution of the indigenous groups; (ii) socioeconomic and health indicators; (iii) legal framework; (iv) institutional arrangements; (v) existing policies, programs, and actions; and (vi) recommendations. A workshop took place in October 1997 that brought together representatives of indigenous groups and indigenous NGOs to launch the Indigenous Peoples Development Plan and discuss further activities. 6. Environmental assessment. Environmental Category: B The project would have a positive environmental impact by specifically addressing the issue of safe handling of insecticides and laboratory and medical materials and waste. It will also help improve the monitoring and control of the population density of animal carriers, reservoirs, and vectors of communicable diseases. The infrastructure and equipment components consider elements of environmental health which will be taken into consideration in the formulation of subprojects (e.g. safety plans addressing such issues such as handling of laboratory chemicals, medical waste, their storage, transportation and disposal, etc.). A guide for the formulation and evaluation of environmental aspects with sections on diagnosis, interpretations, and prevention of situations will form part of the Operational Manual. The project would also include training on the proper handling and disposal of hazardous materials and waste in laboratories and in other areas. 13 7. Participatory approach. Preparation Implementat Operation ion Beneficiaries/community IS, CON, IS, CON, IS, CON, groups COL COL COL Intermediary NGOs IS, CON, IS, CON, IS, CON, COL COL COL Academic institutions IS, CON IS, CON IS, CON Local government IS, CON, IS, CON, IS, CON, COL COL COL Private sector IS, CON, IS, CON, IS, CON, COL COL COL (Note: information sharing (IS); consultation (CON); and collaboration (COL). Primary beneficiaries and other affected groups as well as other key stakeholders have been analyzed in the "social" section earlier. F: Sustainability and Risks 1. Sustainability: This project builds up on the heritage of previous projects such as the Amazon Basin Malaria and Northeast Endemic Control projects which have left behind a strong base from which Brazil can continue to carry on its already successful malaria and other endemic diseases control program. These projects have provided basic infrastructure, equipment and training to technicians and managers at the state and municipal levels. They have started a culture of management and accountability which did not exist before. A second element in favor of sustainability is the consultation undertaken during preparation by the FNS with the various stakeholders involved, particularly those at the state, municipal, and community levels who will have key roles in project implementation. Recently, this process was expanded to include other key partners such as research institutions, universities, and NGOs. The FNS also held extensive discussions with indigenous groups and indigenous NGOs about the project. A third element that supports the project's sustainability is the MOH's Basic Operating Norm of January 1996 which defines the financing modalities to pay for health surveillance and disease control activities and was discussed earlier in the Economic Issues section. 14 2. Critical Risks (reflecting assumptions in the fourth column ofAnnex 1): Annex 1, cell "from Outputs to Objective" Resistance of management and Medium/low Involving the major operational staff to changed roles stakeholders at an early stage of project preparation. Clear definition of the tasks and responsibilities at three levels of government during preparation mission, with clear restructure of the FNS. Number and variety of actors Low/medium Assigning clear project involved (federal, states and management responsibilities to municipalities) be coordinated by the PCU, flexible project design and clear definition of major participants' role in the project Approval of poor-quality Low/medium Using transparent eligibility and subprojects on the basis of evaluation criteria for the political patronage selection of subprojects; independent monitoring; and financial audit Overall Risk Rating Low/medium Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N (Negligible or Low Risk) 3. Possible Controversial Aspects: None G: Main Loan Conditions 1. Effectiveness Condition: establishment of financial management system for the project. 2. Other (a) adherence to Operational Manual; (b) mid-term review in September 2000; (c) contracting of a procurement audit every year on terms and conditions satisfactory to the Bank; and (d) maintenance of PCU acceptance to the Bank. H: Readiness for Implementation. The Project Implementation Plan (see Annex 2) has been appraised and found to be realistic and of satisfactory quality. I. Compliance with Bank Policies. This project complies with all applicable Bank policies. 15 Team Leader: Jean-Jacques de St. Antoine, LCSHD Sector Director: Xavier Coll, LCHSD Country Direc iT. Nankai Annex la BRAZIL - Disease Surveillance and Control Project (VIGISUS) Vision of Disease Surveillance System The Brazilian diseases surveillance The system has been reorganized and modernized. system has a 20-year positive track It is more efficient, more flexible, and better record. However, it has become responsive to local needs of the population and to bureaucratic and less efficient. emerging problems. The scope of the system is largely limited The scope of system is broader and includes the to communicable diseases. The approach monitoring of risk factors, notifiable and chronic is almost exclusively clinical and leads to conditions, injuries, and control actions. As a result, medical solutions. there is more focus on lifestyle changes and enhanced coordination with other sectors such as agriculture and the environment. The national surveillance system is flexible and adapts itself as illness patterns change and new priorities emerge. The degree of reporting and analysis increases with incidence of diseases and conditions. The list of notifiable diseases is better adapted to each state's epidemiological profile. A centralized FNS continues to implement A population-based surveillance system collects a series of parallel vertical programs (such and analyzes medical information on individuals in as tuberculosis, dengue, leishmaniasis, a well-defined population. The surveillance system etc.). Each program is independent and is now decentralized and most of FNS staff has performs everything from surveillance to been transferred to municipalities and states. The control, and sometimes treatment. Some community and health providers have a strong integration has started under the Bank- awareness and ownership of the system. financed Amazon Basin malaria and NE Municipalities undertake primary data collection, Endemic Diseases projects. outbreak investigation, and disease control. States have a coordinating role and provide technical assistance to municipalities, notably with outbreak investigation. A reduced core staff of about 3,000 at the center provide a strong leadership in the organization and contents of the national surveillance system, analyze data, provide feedback to states and municipalities on epidemiological trends and achievements compared to targets, and give technical support to weaker states. The laboratory network has a highly- The laboratory network has been rehabilitated and qualified staff, but the equipment is equipped. It is properly linked with the national becoming obsolete, and needs upgrading. surveillance system. There is good coordination Laboratories have access to telephone between the federal, state, and municipal levels. and fax, but very few of them have access Training programs have strengthened the staff's to the Internet. There is a lack of biosafety awareness and practices. coordination between central, state, and municipal laboratories. The staff do not receive clear guidance as to the type of surveillance information to be collected. There are deficiencies in biosafety. The FNS staff is loyal and dedicated. The staff in states and municipalities have broader Researchers and physicians have skills, are more analytical and practical, and scientific and clinical competence. A large establish a better link between knowledge and proportion of the staff has a strong field operations. The staff at the central level have taken experience. on their normative and supervisory role. Most staff are maintaining their skills through regular training responsive to local needs and new information technology. A centralized budget finances FNS staff The financing system is decentralized as and operational expenses. municipalities receive financing for disease Decentralization has begun through surveillance and control under the SUS', directly financing agreements with municipalities. related to production performance. Municipalities Under these agreements, FNS staff have and states have started to recruit their own staff for started to be transferred to municipalities. disease surveillance to replace those under contract with the FNS who have retired. Public relation with the press is poor. Better public relations allow more objective News reports in the media portray disease information of the public and a more constructive outbreaks as a failure of the health portrayal of the MOH's role in disease prevention system. and control. It also starts to influence the population on lifestyle changes. More work remains to be done as part of the media is still critical. Coordination with neighboring countries is Brazil has significantly increased its technical just starting. cooperation and exchange of experience with neighboring countries in the response to outbreaks of international significance. Border laboratories have become an important instrument to that effect. There is limited evaluation of the Rigorous evaluation of the system has started, performance of the system. using objective factors such as capacity of the system to monitor each health event taking into consideration sensitivity2 and specificity3, the efficiency, representativeness, timeliness, and flexibility of the system, the feedback provided, the level of training of the personnel, the use of data for decision-making, and the speed of response to outbreaks. 'the SUS is Brazil's Unified Health System 2 sensitivity is the proportion of persons with a disease/health event that are detected by the surveillance system 3specificity is the proportion of persons without a disease/health event that are detected by the surveillance system Annex lb BRAZIL - Disease Surveillance and Control Project (VIGISUS) Project Design Summary Sector-related CAS Goal: (Goal to Bank Mission) MOH statistics Improve the health of the Sustainable and population by reducing mortality adequate national and morbidity disease surveillance __________________________ __________________ _ tand control system Program Purpose: End-of-Program Indicators (by 2004) To improve and strengthen the The scope of the surveillance * National and FNS national surveillance system system is not limited to clinical policy documents (NSS) to contribute to reduce interventions but includes the * Project supervision morbidity and mortality from monitoring of risk factors, notifiable mission selected diseases and chronic conditions, injuries and mission control actions. The population surveillance system is decentralized, all municipalities undertake primary data collection, and large ones also carry out outbreak investigation and disease control. All the laboratory network has _ been rehabilitated, is well equipped and is linked by computer systems. Operational staff has increased their competence Evaluation of the appropriateness of the system is periodically undertaken. At least half of the municipalities have directly benefited from project funding VIGISUS Phase 1(1999-2001) Viable framework for the new national surveillance system is developed and tested VIGISUS Phase 11(2002-2003) National surveillance system established in all states and at least 300 municipalities VIGISUS Phase III (2003-2004) National surveillance system fully operational in a decentralized manner Project Development (Objective to Goal) Objectives VIGISUS 1 (1999-2001) Viable framework for the new national surveillance system is developed and tested Outputs: (Outputs to Objective) Strengthened policy and VIGISUS program strategy and National policy and strategic planing. national plan approved strategy document Management of NSS All states have had key personnel PIU reports, strengthened trained as follows: procurement records, * Field Epidemiology Training and supervision Program: 10 graduates missions * Basic Principles of Outbreak Investigation: 100 graduates * Data for Decision-Making: 25 graduates * Public Health Fellowships: 55 fellowships awarded * Laboratory Biosafety: 400 superior-level and 200 medium-level * Laboratory Reporting: 75 trainers trained * Management Training: 60 public health professionals and administrators trained Surveillance information system Data definition and coding SINAN data and telecommunications standards defined improve New SINAN system in place and operational in 75 percent of public health laboratories States and municipalities All states and one-third of SUS data receive financial resources and municipalities have Intemet access support services to sustain and improve NSS Proper mechanism in place to transfer funds for disease surveillance under the SUS Public heaflth laboratories Nine national reference Project supervision network under rehabilitation, laboratories rehabilitated and construction, and being equipped; and nine border provided with adequate laboratories constructed and equipment equipped A coordination mechanism is A liaison council constituted by Minutes of the operating that ensures the representatives of the public and meetings of state participation of private doctors private sectors operates in at least council 10 states. Disease control strengthened in 60 high-level staff trained in the Amazon region (in the 321 communicable disease control Training and municipalities included in the performance evaluation project) 400 community health agents trained for disease control activities 300 health professionals trained to act as local trainers for control of .___ leishmaniosis (LTA and LV) Vaccination coverage for hepatitis B for population aged 0-15 years old increased to at least 90 percent The number of cases of tuberculosis cured in the Amazon Region would have increased by at least 10 percent At least 50 percent of budget spent on non-insecticide vector control methods (early diagnosis and treatment) 700 indigenous community health agents trained Institutional capacity to deliver health services to indigenous populations improved Project Components/Sub- Inputs: (budget for each (Components to components: (see Annex 2 for component) Outputs) project description) . Strengthening of the * Project reports National Surveillance System US$141 million * Financial * Timely availability monitoring of counterpart - Strengthening of Disease * Disbursement funds Control in Selected Areas US$44 million reports * Appointment of * Audits competent staff to - Project Management US$15 million * Management and coordinate project financial reports activities * Contracts Narrative Summary Ky^ Performace Indica'tors Means 0o Verification C .pion' Project Development (Objective to Goal) Objectives VIGISUS 11(2002-2003) National surveillance system established in all states and at least 300 municipalities Outputs: (Outputs to Objective) Strengthened policy and VIGISUS program strategy and National policy and strategic planing. national plan under implementation strategy documents Management of NSS All states have had key personnel PIU reports, strengthened trained as follows: procurement records, * Field Epidemiology Training and supervision Program: 20 graduates missions * Basic Principles of Outbreak Investigation: 100 graduates * Data for Decision-Making: 50 graduates * Public Health Fellowships: 55 fellowships awarded * Laboratory Biosafety: 600 superior-level and 300 medium-level * Laboratory Reporting: 150 trainers trained * Management Training: 120 public health professionals and administrators trained Surveillance information system New SINAN system in place and SINAN data and telecommunications operational in 85 percent of public improve health laboratories All states and 45 percent of municipalities have Internet access States and municipalities Proper mechanism remains in SUS data receive financial resources and place to transfer funds for disease support services to sustain and surveillance under the SUS improve NSS Public health laboratories Twelve national reference Project supervision network under rehabilitation, laboratories rehabilitated and construction, and being equipped; and 12 border provided with adequate laboratories constructed and equipment equipped A coordination mechanism is A liaison council constituted by Minutes of the operating that ensures the representatives of the public and meetings of state participation of private doctors private sectors operates in at least council 20 states. Disease control strengthened in 90 high-level staff trained in Training and the Amazon region (in the 321 communicable disease control performance evaluation municipalities included in the project) 500 community health agents trained for disease control activities 400 health professionals trained to act as local trainers for control of leishmaniosis (LTA and LV) Vaccination coverage for hepatitis B for population aged 0-15 years old increased to at least 95 percent The number of cases of tuberculosis cured in the Amazon Region would have increased by at least 13 percent At least 50 percent of budget continues to be spent on non- insecticide vector control methods (early diagnosis and treatment) 1000 indigenous community health agents trained Institutional capacity to deliver heaith services to indigenous populations improved Annex 2 BRAZIL - Disease Surveillance and Control Project (VIGISUS) Detailed Project Description and Project Implementation Plan Component I - Strengthening of National Surveillance System (US$141 million, 70.5 percent of project cost). This component, to be implemented nationally, includes: (i) improvement of the data management telecommunications system; (ii) rehabilitation, extension, and equipment of the laboratory network; (iii) rehabilitation and expansion of cold storage facilities; (iv) rehabilitation and expansion of environmental surveillance facilities; (v) training of municipal, state, and central FNS staff; and (vi) studies and research in epidemiological surveillance. Improvement of the Data Management Telecommunications System. This subcomponent will: (i) provide micro-computers, printers, telephone access, and vehicles to municipalities; (ii) develop and implement new modules for the public health information system; (iii) provide technical assistance to help the states and municipalities resolve practical issues (such as provision of hardware, software, and training) in implementing the improved and standardized surveillance programs envisioned by VIGISUS; and (iv) improve the data telecommunications system at the FNS central level. As regards activity (i), municipalities will present subprojects in accordance with population-based eligibility criteria in the Operational Manual. They would have to demonstrate their need for the equipment, and their capacity to maintain it. Laboratory Network. This subcomponent will finance: (i) the upgrading of 12 existing national reference laboratories to convert them from the BSL-2 to the BSL-3 category; (ii) the construction of 12 border laboratories; and (iii) the upgrading and construction of about 50 zoonoses centers. Details on the Brazilian system of public health laboratories are provided in Annex 10. Cold Storage Facilities. This subcomponent will finance the rehabilitation, expansion, and equipment of about 60 cold storage facilities to strengthen the distribution and storage of vaccines and other perishable medical products. Environmental Surveillance Facilities. This subcomponent will finance the rehabilitation and equipment of regional entomology centers, and water, air, and soil quality laboratories. Training. This subcomponent will train municipal, state, and central FNS staff in epidemiology, laboratory reporting, laboratory biosafety, environmental surveillance, and management. Details on the training program (curriculum description, target personnel, provider, and costs) are provided in Annex 12. Studies and research in Epidemiological Surveillance. This subcomponent will finance: (i) studies on the development and implementation of health indicators; (ii) periodical population- based health analyses; (iii) monitoring and evaluation of specific diseases; and (iv) publication of epidemiological analyses, guides, and manuals. Technical Assistance. This subcomponent will finance technical assistance to help municipalities and states in subproject preparation, appraisal, and supervision, as well as procurement. Component II - Strengthening of Disease Control in Selected Areas (US$44 million, 22 percent of project cost). This component includes; (i) disease control in the Amazon Region; and (ii) indigenous health. A significant participation of NGOs is expected. Disease Control in the Amazon Region. This subcomponent, to be implemented in the nine states of the Amazon Region, will finance: (i) the rehabilitation, expansion, and equipment of public health laboratories and other health facilities in the Amazon region; (ii) boats and vehicles; (iii) training of 540 community health agents, management training for about 50 public health officials, and training of 90 technicians in communicable disease surveillance and control; (iv) antimalarial drugs and reagent kits for the diagnosis of hepatitis, leishmaniasis, and malaria; and (v) technical assistance. Indigenous Health. This subcomponent will finance: (i) the rehabilitation and equipment of health centers, health posts, environmental health, and other health facilities adapted to the indigenous culture; (ii) equipment (such as boats, engines, vehicles, and geographical positioning systems - GPS); (iii) training of 1000 indigenous health agents; and (iv) technical assistance. Component III - Project Administration (US$15 million, 7.5 percent of project cost). This component would help finance the administrative and operating costs of the PCU over a 3-year period. This includes: (i) financing of PCU consultants; (ii) travel; (iii) training; (iv) equipment; and (v) other administrative expenses (materials etc. ). Project Design. The project is partly pre-designed and partly implemented on the basis of subprojects presented by decentralized institutions. For the pre-designed part, this means that an analysis of needs, a survey of existing infrastructure and equipment, and a skills analysis of the disease surveillance and control staff, have led to a detailed definition of a core group of activities that needed to be designed in a planned fashion so as to ensure a coherent and coordinated effort to strengthen the data management telecommunications system, the network of laboratories, and upgrade the skills of the staff. This represents about 40 percent of the project cost. The rest of the project (60 percent of the project cost) will come under the form of subprojects to be presented by municipalities, states, NGOs, and other institutions. These subprojects would represent the needs of these municipalities etc. to complement the pre-designed part. To ensure that they fit within the overall framework, comply with the norms of the FNS, and are properly targeted, subprojects will be prepared and evaluated according to eligibility and evaluation criteria included in the Operational Manual, and presented in Annex 13. Funds are targeted to states and municipalities using a transparent allocation formula based upon population and incidence of disease. The breakdown between the pre-designed activities and subprojects is presented in the following project cost table Project Cost (US$'000) Pr-esge Subprct - otal Disease Surveillance System l Computer network - 21175 21175 Laboratories 7318 1325 8643 Cold Chain - 5000 5000 Environmental Surv. Facilities 7382 19000 26382 Training 15152 37000 52152 Studies and Research 18950 - 18950 Technical Assistance' 8698 - 8698 Subtotal 57500 83500 141000 (40%) (60%) Disease Control in Selected Areas Amazon Laboratories and other infrast. - 6100 6100 Training 4204 11228 15432 Drugs and Pharm. Products - 4572 4572 Technical Assistance2 4896 4896 Subtotal 9100 21900 31000 Indigenous Health Infrastructure 2014 4000 6014 Equipment 1425 1600 3025 Training 1461 1800 3261 Subtotal 5600 7400 13000 Subtotal Disease Control 14700 29300 44000 (33%) (67%) Project Administration Consultants3 14147 14147 Training 346 346 Equipment 360 360 Other Expenses 147 147 Subtotal 15000 - 15000 Grand Total 87200 112800 200000 I includes supervision 2 includes supervision 3 includes monitoring and evaluation Implementation Plan. Please see next page. Implementation Plan: VIGISUS Components and Activities Year 1 Year 2 Year 3 IJ F M A M J J A S O N D IJ F M A M J J A S O N D IJ F M A M J J A S O N D Project Area I - Epidemiological Surveillance Component I ' 4 4 ,, .... ... ... ... ... ... ... ............. C om one ntI 1] .+>w i,,, ,, i ,,,, , ,,, , ,, i ,,,, i ...... i i t,,,i,,,,,i, i ...... - -~~~~~~.... .... . ... ..... ... 1: .... .... ... .. Preliminary Meetings . 1 IIII* III Implementation of Integrated Projects * t I TlT l Component 11 Com onentil E * S S i i E * ..... i i i ! i i i i i i - i i ..... | E i ,i,~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~... ...................... ....... .... ... Physical Repairs and Equipment Supply .... . . 'i e ' ' Techtnical Visits i ..... ... ..... ................ ............ Architectural Consulting - U . Training in Applie Epidemiology .......j; ; .ii;j,, ., . iii Field Epidemiology Training Program . i ~I~ Basic Principles of Outbreak Investigation i.l!i-EiL!... Data for Decision Making ; ! 'i ! ! ! i ! ! 'i ! ..................... ...... .... Short CourseslWorkshops (Fellowships) .... j ..... ...... i ...... ..... Ot ert ining .. i i i ' ........ ; i E X M i E ! | i . i i ; E ...... i.,.~~~~~~~~~~~~~~~~~~~~~~~~~..... .... ... ........ ... ... ... ... ... ....... ... ... .. .... ? 1 ? ......... i.... ........ ..... ;..... g.... ..... ..... .... ..... ... ..... .... OTheraiingoTring r Laboratory ofwaeoftwareIIIIII, M h hIIM SINAN Softwmare IIIIiiIi ii.j!i iIIIIIIggIIII IT!!!!!!!!!!! Development of Systems and Services ! _ --F- --4--i--4------- .---.--i- . i-4--4F -------i ..... i* - F---F--F--F.-.---i. Inf emcation Centers .... ........... . .....,. Specific Problems ..... i t .................. _ ........................... Epidemiology - m Incenies f Epidemiolo ican Development Studies Requested by FNS i V National Bidding: Epidemiology ij. These actIvIites will occur throughout the duration of the proJect j Institutional Research ... I i ..... 4.i S upport to emerging groups for teaching and research in epidemiology ..... . ..... . Seminars Intemational Consulting ...._________________.____.___.____.___.____._________________F_.......T. National Consulting i i - i L i i i * 1 L I ! ..1............. t i L j E i L L L - ... Page 1 Implementation Plan: VIGISUS Components and Activifies 1 Year 1 Year 2 Year 3 J F MA MJ J A S O N D J F M A M J J A S O N DIJ F M A M J J A S O N D Project Area II: Environmental Surveillance Component I .....-....i.. … Preliminary Meetings -. t -,. ...... : + i t i ! : S i . . W r > v ; z i~~~~~~~~~~~~~~~~~~i... . ... Implementation of Integrated Projects * ..... .-.-- - --.Ifl.i.hh, Component If ---- 4 . . . ... ....... ..... . .. .......... Com one ntil ......... . ..................... ...... - 1 - .......................... .............................. | . ... Conditional Risk Factors for the Transmission of Diseases Drinking Water These actlvMtles will take place throughout the duration of the project Environmental Contamination Air Quality Soil Contamination Natural Disasters and Accidents with dangerous substances ______t Integrated Actions for Environmental Surveillance ... *'' ----- *.-- .. , Project Area Ill: Activities for Disease Control in the Amazon Component I Comp nen I _ _ ___- _ _ ............. i i i - i j ; E i i E ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~,j gi j,~~~~~ i;- .................. i i j j ..... i~~~~~~A i i.... .... l . *'" i--- '.---'--"i' -' ii ii i i i . Li ......................................................................................_ , ii_.ii.i._................-.-----.._ _--i---- Preliminary Meetings . ....... Implementation of Integrated Projects Component l .... II. . ...... ........... .... ..... ... .... .... .... .. .... ... .... ... ... , . ... ...,. ,,,,, , , .....,i, .....i,,i , ,, 1 Meetingsineach U.F . . . . . . 2 State Seminars _ . . i ...... 3 Regional Seminars.............................................. 4 Meetings in the States 5 Communication Campaigns 6 Campaign Networks 7 Management Courses 8 Courses in Epidemiology and Disease Control ............. ...... ..... 9 Capacity-Building and Supervision Activities. PACs 12 Acquisition of Software:SIG r r 13 Acquisition of Equipment: GIC *- - - . t . ........ ................ .......... 14 Acquisition ofAnti-Malarals ....*...- . . Program Area IV: Indigenous Health Component I ......---'-----i . ., -.. .... . , .i............. Preliminary Meetings ...t . .... t IIIIhi . I. r. Implementation . I hIhIhIhIIIh. IIIIE P .2 ..... Page 2 Implementation Plan: VIGISUS Components and Activities Year 1 Year 2 Year 3 _____________________________JFMAMJJASOND JFMAMJJASOND| FMAMJJASOND Component 1I - . . . . ..,,,,, .,, ,I g i , g g - Z ,,g .... ...... 1.- Training of indigenous health agents .. t _ . r _ ..r 2.- Reform and construction of Health Posts 3.- Water supply and sanitation system 4.- Construction and Rehabilitation of Indigenous Clinics - 5.- Infrastructure of Indigenous Organizations 6.- Equipment 6.- Equipment ..... .. j I,, y ............ @gli ...... ......~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~... ... .... 7.- Design and Construction of Inter-institutional Centers for Indigenous Health B.- Teacher Training for Centers for Indigenous Health 4 i 9.- Training of healthcare professionals in environrnental and epidemiological surveillance b...., . 4~~~~~~~~~~~~~~~~~........LLLiL Page 3 Annex 3 BRAZIL - Disease Surveillance and Control Project (VIGISUS) Estimated Project Cost (US$ million) Strengthening of the Disease 86.2 39.0 125.2 Surveillance System Strengthening of Disease 19.7 7.0 26.7 Control in Selected Areas PCU 12.5 2.0 14.5 Total Baseline Costs 118.4 48.0 166.4 Physical Contingencies 15.4 - 15.4 Price Contingencies 18.2 18.2 TotalProjet Cos Annex 4 BRAZIL - Disease Surveillance and Control Project (VIGISUS) Financial Summary Calendar Year Ending December 31 (US$ million) 7r777777~~~~7 V i ,A*)v ; -X- " : - Project Cost ___T_i_I Investment Cost 40.0 70.0 70.0 20.0 200.0 Total 40.0 70.0 70.0 20.0 200.0 Financing Sources Bank 20.0 35.0 35.0 10.0 100.0 Government 20.0 35.0 35.0 10.0 100.0 Annex 5 BRAZIL - Disease Surveillance and Control Project (VIGISUS) Procurement and Disbursement Arrangements Procurement Procurement of goods and services will be carried out in accordance with the Bank's Procurement Guidelines (Guidelines: Procurement under IBRD Loans and IDA Credits, version dated January 1995, revised January and August 1996, and September 1997). Civil works for laboratories, cold storage, and other health facilities costing between US$350,000 and US$5 million per contract will be procured through NCB up to an aggregate amount of US$10 million. Civil works for contracts below US$350,000 will be procured through three quotations (lump-sum fixed price contracts) up to an aggregate amount of US$5 million. Equipment for laboratories, cold storage, and other health facilities costing more than US$350,000 per contract will be procured through ICB up to an aggregate amount of US$12.3 million. Equipment costing between US$100,000 and US$350,000 will be procured by NCB up to an aggregate amount of US$48.4 million. For the procurement of project components under NCB procedures, standard bidding documents, acceptable to the Bank, will be used. Drugs and pharmaceutical materials will be procured through the Panamerican Health Organization, using Bank procurement guidelines. This is because the Borrower lacks the appropriate organization, resources, and experience in the area of drugs and pharmaceutical products, especially in the area of control of quality and validity period of drugs. In its contract with the Borrower, PAHO will include a training plan to build local institutional capacity to that effect. Consultant services for firms would be selected following the Bank's Guidelines: Selection and Employment of Consultants by World Bank Borrowers (January 1997, revised September 1997). These services would be selected in accordance with Quality- and Cost-Based Selection (QCBS) procedures up to an aggregate amount of US$17 million. Specialized consultant services in disease and environmental surveillance and control may be contracted with the Centers for Disease Control under sole-source contracting up to an aggregate amount of US$2 million. Contract thresholds, modalities, and Bank financing ratios are indicated in Tables A, B, and C of this Annex. Disbursement The PCU would present disbursement requests based on Statements of Expenditure for all payments against (i) Civil Works contracts valued less than $350,000 except for the two first contracts which require the Bank's prior review and full supporting documentation; (ii) Goods contracts valued less than $100,000 except for the first two contracts which require the Bank's prior review and full supporting documentation; (iii) contracts for consulting firms valued at less than $100,000, and (iv) contracts for individual consultants valued at less than $50,000. A Special Account for a total of $10,000,000 would be authorized for this project, with an initial allocation of $2.5 million. Replenishments would be presented to the Bank on a monthly basis, along with special account reconciliations. Allocation of Loan Proceeds (Table C) Table A Project Costs by Procurement Arrangements' (US$ million) Civil Works 10.0 5.0 15.0 (5.0) (2.5) (7.5) Goods: 12.3 48.4 1.0 61.7 Equipment (6.2) (24.1) (0.5) (30.8) Drugs and 4.6 4.6 Pharm. Products (2.3) (2.3) Training 71.2 71.2 (35.6) (35.6) Consultants ~~~~~~~ ~ ~~~(23.7) =(23.7) Other 0.2 _0.2 Figures in parentheses are the amounts to be financed by the Bank loan ICB = International Competitive Bidding NBF = Not Bank-financed NCB = National Competitive Bidding Other = Includes consultants and TA lTotals include taxes and contingencies. Amounts in parentheses show allocations of Bank Loan proceeds 2 Not Bank-financed Annex 5, Table Al: Consultant Selection Arrangements (in US$ million equivalent) Consultant Services QCBS QBS SFB LCS CQ Other N.B.F. Total (including. Expenditure Category l contingencies) A. Firms 17.0 l 2.0 19.0 B. Individuals T 28.3 28.3 Total 17.0 l 30.3 47.3 Note: QCBS = Quality- and Cost-Based Selection QBS = Quality-based Selection SFB = Selection under a Fixed Budget LCS = Least-Cost Selection CQ = Selection Based on Consultants' Qualifications Other = Selection of individual consultants (per Section V of Consultants Guidelines), Commercial Practices, etc. N.B.F. = Not Bank-financed. Figures in parenthesis are the amounts to be financed by the Bank loan. Annex 5, Table B: Thresholds for Procurement Methods and Prior Review Contmats Subject to Expenditure . Contract Value Procurement Prior Review / ; Ctegory E >-(Thireshd) Me tod Estimated Total Value __ - -: ~ .; - . : -- -Subject to Prior Review 1. Civil Works Above 5,000,000 ICB Prior review for all 350,000-5,000,000 NCB Prior review of first two contracts every year Less than 350,000 3 Quotations3 Ex-post review 2. Goods Above 350,000 ICB Prior review for all 100,000-350,000 NCB Prior review of first two contracts every year Less than 100,000 Shopping4 Ex-post review 3. Training Firms Above $100,000 QCBS All Less than $100,000 QCBS TORs Individuals Above $50,0001/ Individuals All Less than $50,000 Individuals TORs 4. Consultants Firns Above $100,000 QCBS All Less than $100,000 QCBS TORs Individuals Above $50,0001/ Individuals All Less than $50,000 Individuals TORs Total value of contracts subject to prior review: 60% (estimated) 1/ When justifiable; individual consultants will be contracted in accordance with Section V of the "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" published by the Bank in January 1997 and revised in September 1997. 3 Lumpsum fixed price contracts 4 National and international Annex 5, Table C: Allocation of Loan Proceeds Subprojects 66.0 60% of the amounts disbursed Works 5.5 50% Goods 5.3 50% Consultant Services 9.9 25% Training 10.3 50% Unallocated 3.0 I=_ Annex 6 BRAZIL - Disease Surveillance and Control Project (VIGISUS) Economic Analysis The economic analysis of this project focuses on two issues: whether the surveillance component (which accounts for 71% of project costs) is feasible and whether the project is sustainable. The cost-effectiveness of disease control has been thoroughly analyzed in the context of previous projects', and the findings of these studies were integrated into the design of the disease control component of this project. These findings are summarized in section I below. Since this would be the first project in the Bank with significant financing for a disease surveillance system, the economic rationale of the surveillance component was examined more thoroughly2. The discussion is presented in section 2 below. The question of the sustainability of the project also needed to be examined in the light of the current changes in the financing strategy of basic health care and surveillance activities. The findings are summarized in section 3. This annex concludes with a summary discussion following OPR guidelines on economic analysis. 1. DISEASE CONTROL IN THE AMAZON REGION In this section, we summarize the main findings of the previous analyses that were carried out on endemic disease control in the Northeast and Amazon regions and that were integrated into the design of this project. 1.1 THE NORTHEAST ENDEMIC DISEASE CONTROL PROJECT The project, which closed on June 30, 1996, had the following objectives: reduce the prevalence of Chagas' disease, schistosomiasis, and leishmaniasis in the Northeast, and bring the intensity of human infection to minimum levels where only epidemiological surveillance activities would be needed to keep these diseases under control. 1.1.1 Chagas' disease The strategies for control of Chagas' disease included interrupting transfusion transmissions and eradicating the vector (Triatoma infestans). More specifically, the project financed the purchase See especially ICRs for the Northeast Endemic Disease Control Project (July 1997), and the Amazon Basin Malaria Control Project (May 1997). 2 For lack of time, the appraisal team has not been able to carry out a cost-effectiveness study of surveillance for all the diseases and on a regional basis. Such an analysis, carried out early into the project, would help towards defining cost-effective strategies for specific diseases and specific regions. of insecticides, trained field inspectors, created a serologic surveillance system based on 12 reference laboratories, controlled transmission via contaminated transfusions (including through legislation), and left a network of well-equipped personal health services which provide care for Chagas patients. The project is estimated to have prevented about 12,500 cases of Chagas' disease and 3,800 deaths, which translates into about 72,900 DALYs saved. Given the US$23 million involved, the project cost about U$$260 per DALY saved, which places it among the most cost-effective health interventions. 1.1.2 Schistosomiasis The strategy for the control of schistosomiasis included: (i) early diagnosis and treatment of infected people; (ii) basic household sanitation; and (iii) information, education and communication (IEC). The project installed laboratories, provided supplies and equipment and trained local agents to perform diagnostic tests and refer patients for treatment in the network of local health care services. In addition the project piloted the introduction of mass-treatment of schistosomiasis in school health programs and in municipalities with a high incidence of disease. The project also helped set up health promotion teams at the municipal level which carried out significant amount of IEC activities. The project showed that it is very difficult to eliminate low- level transmission with the traditional control approach. Disease eradication depends very much on environmental and household sanitary conditions. The project is estimated to have prevented at least 3,400 schistosomiasis deaths, which translates into 67,000 DALYs saved. The interventions, at US$980 per DALY saved were moderately cost-effective. 1.1.3 Leishmaniasis The strategy focussed on establishing an adequate information system, on establishing laboratories capable of diagnosing the disease, and on training doctors and other health care personnel in the appropriate treatment of the disease. In the case of kala-azar, the project set up a network of laboratories, provided equipment and supplies for controlling the sandflies, established a network of municipal kennels equipped for diagnosing and eliminating infested dogs, and established treatment protocols, trained doctors and other health care personnel in treating the disease. Treatment of this form of the disease requires specialized medical expertise, which most physicians did not have. Therefore, one of the main contributions of the project to the reduction of the incidence of the disease was the establishment of treatment protocols for kala-azar, training of medical personnel and the provision of an effective chemotherapeutic agent. The project is estimated to have prevented 770 cases of kala-azar, and avoided 11,300 deaths which translates into 380,000 DALYs gained. The component cost about US$140 per DALY saved, which places it among the most cost-effective public health programs. 1.2 THE AMAZON BASIN MALARIA CONTROL PROJECT The project, which closed on June 30, 1996, tested two major changes to the traditional malaria eradication paradigm. First the project began to target vector control activities to a number of municipalities, and localities with highest malaria incidence, to control the spread of the disease, as opposed to the traditional approach to making widespread use of insecticides to eradicate the disease. After 1992, the projected tested a shift from the traditional focus on reducing malaria incidence through vector control, to reducing severity of the disease through early diagnosis and effective treatment of patients. Hospital and ambulatory centers were equipped and staff were trained to aggressively diagnose and treat malaria. Between June 1988 and June 1996, the Malaria Control Program prevented 1.9 million new malaria cases and averted 236,000 deaths, which translates into a total of 8.8 million DALYs saved. As at cost-effectiveness of US$67 per DALY saved and US$ 260 per case averted, the program falls into the category of high cost-effectiveness interventions. 2. ENVIRONMENTAL AND EPIDEMIOLOGICAL SURVEILLANCE COMPONENT 2.1 COST-BENEFITANALYSIS 2.1.1 Introduction The reinforcement of the surveillance system is expected to yield benefits of several kinds. The analysis focuses on three of them: savings on hospital costs, productivity gains from lower morbidity and productivity gains from averted mortality. Several other types of benefits would also be produced by the project but have not been calculated because of the difficulties of estimation. For example, a more efficient information flow would produce direct savings by reducing duplications and simplifying procedures3. The project would also generate positive externalities; the reduction of the incidence in malaria in the State of Amazonas, for example, could enable the emergence of a tourism industry. The computation of benefits is remains a controversial endeavor4. The present analysis makes clear the hypotheses and parameters that were retained so that the reader can independently gauge their conceptual and numerical validity. The cost-benefit analysis is followed by a risk analysis that tests the robustness of the computed rates of return to changes in all the key parameters. The surveillance system is expected to have an impact on the occurrence of all forty- 3 See Ostroff and Hamilton's "Review of the Brazilian Epidemiological Surveillance System," Nov. 1997. 4 For a discussion of the issue of valuation of life see, among others, Anne Mills. one notifiable diseases. We limit the cost-benefit analysis here to seventeen of these for lack of data. Given the difficulty of modeling the benefits associated with the surveillance system, and the weak basis for some of the assumptions, the results of this simulation should be interpreted with caution. 2.1.2 Benefits from hospital-days saved The surveillance system will have an impact on the epidemiological pattern of infectious diseases because it will increase the sensitivity5 of disease detection, quicken detection and shorten response lags6, eventually leading to a lower number of cases requiring hospitalization. The extent to which the reinforcement of the surveillance system will translate into hospital-days saved is difficult to assess ex-ante. As a result we have made very conservative assumptions that are based upon discussions with the Brazilian National Health Foundation and Bank health sector specialists - summarized in table la below - with a view to reinforce the robustness of the results. In most cases, the percentage decrease in hospital-days is estimated at 1 percent, and the highest decrease is estimated at 10 percent. 5 Sensitivity is defined as the proportion of cases notified that are real occurrences of the disease. 6 For exanple, the project purports to reduce the time lag between collection to compilation at national level from 24 months to 12 months for mortality data and from 3 month to I month for morbidity data. Table la: Expected savings on hospital costs Diseases Prevailing Percentage Hospitzn Average Hospital Cost Savings on Number of decrease averted hospitzn averted hospital-day hospital costs hospitzn/ year7 due to survei_ (R$)8 (R$) Measles 371 1.0% 4 4.6 17 29.36 501 Poliomyelitis/PFA 144 1.0% 1 13.1 19 27.48 518 Diphtheria 266 1.0% 3 7.6 20 26.02 526 Whooping Cough 917 1.0% 9 6.8 62 23.20 1,447 Tetanus 1,360 1.0% 14 12.6 171 54.14 9,278 Meningitis 28 1.0% 0 9.7 3 41.45 113 Neonatal Tetanus 17 1.0% 0 9.2 2 35.13 55 Hepatitis 16 1.0% 0 6.2 1 19.58 19 Cholera 17,714 10.0% 1,771 4.1 7,263 32.06 232,815 Rabies 61 10.0% 6 3.8 23 39.12 907 Leptospirosis 65 1.0% 1 8.0 5 28.80 150 Tuberculosis 16,187 10.0% 1,619 34.9 56,493 15.83 894,413 Hansen's disease 11,536 10.0% 1,154 77.5 89,404 15.92 1,423,139 Malaria 39 1.0% 0 4.3 2 19.18 32 Leishmaniasis 4 1.0% 0 14.9 1 14.15 8 Chagas 568 5.0% 28 8.5 241 76.00 18,346 Schistosomiasis 2 1.0% 0 9.2 0 21.26 4 Total 49,295 4,610 153,727 _ 2,582,271 The surveillance system will have a varying impact upon hospitalizations according to a complex of factors. In section 2.2, we check for the robustness of the rates of return calculations against modifications in the two principal assumptions made above: the number of hospitalizations in the absence of a surveillance system, and the percentage decrease in hospitalizations attributable to a reinforced surveillance system. In addition, we suppose that the savings on hospital costs kick-in slowly. We assume that only 20 percent of the potential savings materialize the first year of the project, and then increase by 20 percent per annum from then on - meaning that the full savings on hospital costs occur only from the fifth year onwards of the project life. Table lb summarizes the base pattern of savings given this additional hypothesis: Table lb: Pattern of savings on hospital costs Year Savings on hospital costs (R$) 1999 516,454 2000 1,032,908 2001 1,549,363 2002 2,065,817 2003 2,582,271 2004 2,582,271 2005 2,582,271 2006 2,582,271 2007 2,582,271 2008 2,582,271 2.1.3 Benefits from reduced morbidity 7 Calculated as the average number of hospitalizations for the period 1993-1997. Source: DATASUS 8 Source: DATASUS The second set of benefits derives from the reduction in morbidity associated with earlier detection and control of diseases. This section focuses on the reductions in morbidity attributable to seventeen of the principal notifiable diseases. Morbidity in the absence of surveillance is taken to be that of the average over the period 1993-1996. This hypothesis calls for some caution: if disease prevalence is unusually high during those years, then the hypothesis may tend to over-estimate the impact of surveillance during subsequent years. In the case of malaria, for example, using the average occurrence over the period 1993-1996 could lead to overestimating the benefits of the surveillance system should the epidemic have subsequently abated without reinforcement of surveillance activities. Conversely, in the case of measles, taking the average for 1993-1996 as basis is likely to lead to underestimating the benefits of surveillance. Another reason for caution is that there is significant sub-notification of diseases - a phenomenon that leads to underestimating the benefits of surveillance. The proposed reinforcement of the surveillance system will increase disease reporting. Statistics that show an increase in morbidity (the same applies for mortality9) will have to be read with extra care, as they do not distinguish between real increases in morbidity and mortality and what is the outcome of better notification. Project monitoring and impact evaluation indicators will be especially vulnerable to such erroneous interpretations. The problem of an appropriate base for the estimation of morbidity reductions is tackled in the risk analysis by utilizing a range of plausible values. Morbidity is factored into the cost-benefit analysis through the reduction in its debilitating effect on productivity. The number of days of work lost attributable to each disease was inferred from literature and from hospitalization data and valued at minimum wage level'0. If indeed communicable diseases disproportionately affect the poor working in the informal non-wage sector, then the use of minimum wage surely overestimates the gains in productivity that are attributable to reinforced surveillance. 9 Subnotification of deaths (through the Sistema de Informac6es de Mortalidade) is currently estimated at 15%. The project aims to reduce this to proportion to 10% within three years. An estimated 60% of morbidity cases are not notified through the Sistema de Informa,ces de Agravos de Notificacao. The project aims to reduce this to 0% within three years. 10 Minimum wage is estimated at R$5.60 per day. One alternative is to use GNP per capita to value productivity - which implies that diseases affect people indifferently of their income level. Valuing the productivity loss at prevailing wage rates means that poor and rich people's lives are valued differently, which poses a real ethical problem. Table 2a: Estimated benefits subsequent to reduction in morbidity Disease Prevailing Percentage Cases averted Average days Disability Averted Number of Decrease due due to lost per weights'3 wage loss cases/ yearl I to surveillance surveillance case12 (R$) Measles 5,495 1.0% 55 15 0.152 683 Poliomyelitis/PFA 0 1.0% 0 23,689 0.369 0 Diphtheria 223 1.0% 2 15 0.231 42 Whooping Cough 4,428 1.0% 44 29 0.25014 1,810 Tetanus 1,081 1.0% 11 15 0.640 566 Meningitis 29,819 1.0% 298 -29 0.616 30,036 Neonatal Tetanus 169 1.0% 2 0 0.640 0 Hepatitis 50,124 1.0% 501 62 0.209 36,402 Cholera 38,873 10.0% 3,887 155 0.350 114,287 Rabies 34 10.0% 3 157 0.500 143 Leptospirosis 2,961 1.0% 30 10 Y T.2-5-0 415 Tuberculosis 80,742 10.0% 8,074 548 0.294 7,278,116 Hansen's disease 33,898 10.0% 3,390 2,081 0.153 6,042,564 Malaria 527,677 1.0% 5,277 4 0.172 18,551 Leishmaniasis 35,879 1.0% 359 1,095 0.243 534,624 Chagas 10,00021 5.0% 500 12,301 0.350 12,054,490 Schistosomiasis 214,70122 1.0% 21,433 , 0.005 6,041 Total 1,036,104 _j __ 44,008 39,930 1 26,118,769 In section 1.2 below, we check for the robustness of our rates of return calculations against modifications in the assumptions made above: the number of cases notified in the absence of a surveillance system, and the percentage decrease in hospitalizations attributable to a reinforced surveillance system. Once again, we suppose that 20 percent of the potential benefits from reduced morbidity materialize cumulatively every year - so that the full benefits of reduced I Source: DATASUS, average 1993-1996. 12 Source: Global Health Statistics, Murray C.L., Lopez A.L., 1996. We used the estimates for the LAC region. 13 Our Estimates. 14 Idem. 15 Idem. 16 Idem. 17 Idem. s Idem. 19 Idem. 20 Idem. 21 Idem. 22 Idem. 23 Idem. morbidity occur only from the fifth year onwards. Table 2b summarizes the ensuing base pattern of benefits. Table 2b: Pattern of benefits from reduced morbidity Year Productivity Gains (R$) 1999 5,223,754 2000 10,447,508 2001 15,671,262 2002 20,895,016 2003 26,118,769 2004 26,118,769 2005 26,118,769 2006 26,118,769 2007 26,118,769 2008 26,118,769 2.1.4 Benefits from reduced mortality The third set of benefits that is factored in the analysis derives from the reduction in mortality associated with earlier detection and control of diseases24. The incidence of diseases in the absence of surveillance is taken to be that of the average for the period 1993-1995. The concern expressed in section 2.1.3 applies here as well: if mortality is unusually high in that period, then the hypothesis may tend to over-estimate the expected impact of surveillance. The sub- notification of deaths, on the other hand, lends to an under-estimation of the benefits of the surveillance system. There is no obvious solution to this problem save resorting to a sensitivity analysis to generate a range of plausible values. The number of years of productive life lost ascribable to each disease is calculated by finding the average age of onset of the disease, and using mortality tables to find the life expectancy at onset (see figure 1 below). The debatable assumption made here is that death occurs promptly after onset. 24 Whether averted deaths should be counted as benefits is an unresolved issue. We chose to carry out the cost-benefit analysis including the benefits ascribable to averted mortality. Figure 1: Life Expectancy in 199025 Life expectancy at different ages, 1990 c 60 g40 20 0 IL ) U) IL) Ul) U') LO LO e' cm It LO 0 r~- age 25 Source: Anuario Estatistico do Brasil, IBGE, 1996. Table 3a: Estimated benefits subsequent to reduction in premature mortality Diseases Prevailing Percentage Deaths Years of Life-years Averted loss due No. of deaths Decrease due t averted due Productive to premature per year26 surveillance to surveillanc life after mortality (R$)28 onset27 Measles 11 1.0% 0 69 8 10,208 Poliomyelitis/PFA 0 1.0% 0 70 0 0 Diphtheria 20 1.0% 0 65 13 17,404 Whooping Cough 42 1.0% 0 70 29 39,320 Tetanus 389 1.0% 4 66 255 342,551 Meningitis 2,593 1.0% 26 60 1,558 2,094,076 Neonatal Tetanus 66 1.0% 1 69 46 61,286 Hepatitis 803 1.0% 8 46 371 498,212 Cholera 294 10.0% 29 462 1,341 1,801,899 Rabies 16 10.0% 2 46- 73 98,063 Leptospirosis 347 1.0% 3 443 152 203,943 Tuberculosis 5,910 10.0% 591 39 23,114 31,065,229 Hansen's disease 219 10.0% 22 45 986 1,325,701 Malaria 425 1.0% 4 46 193 259,944 Leishmaniasis 145 1.0% 1 64 93 125,045 Chagas 5,588 5.0% 279 61 17,006 22,856,011 Schistosomiasis 594 1.0% 8 4632 371 364,057 Total 17,462 978 45,508 61,162,948 To remain conservative we again suppose that 20 percent of the potential benefits from reduced mortality materialize cumulatively every year - so that the full benefits of reduced mortality occur only from the fifth year onwards. Table 3b summarizes the base pattern of benefits. 26 Source: DATASUS, average 1993-1995 27 Whether or not to discount years of productive life is yet another unresolved debate. Here we do not discount them. 28 We encounter the same problem vis-a-vis the valuation of productive life as in section 2.1.3 above - with as little consolation to offer for the necessarily erroneous valuation. 29 Our estimates. 30 Idem. 31 Idem. 32 Idem. Table 3b: Pattern of benefits from reduced mortality Year Productivity gains (R$) 1999 12,232,590 2000 24,465,179 2001 36,697,769 2002 48,930,359 2003 61,162,948 2004 61,162,948 2005 61,162,948 2006 61,162,948 2007 61,162,948 2008 61,162,948 2.1.5 Costs The decision has been made that the project will be an Adaptable Program Lending (APL). Table 4 shows the expected annual and cumulative disbursement. Table 4: Expected capital expenditures disbursement profile Brazil Fiscal Year 1999 2000 2001 2002 2003 2004 2005 Total Annual disbursement (%) 13.3 13.3 13.3 15.0 15.0 15.0 15.0 100.0 Cumulative disbursement (%) 13.3 26.6 40.0 55.0 70.0 85.0 100.0 The recurrent costs are calculated as representing 2 percent of the capital costs incurred during the year. They are cumulative and perennial. In the section on risk analysis, we test the robustness of the results against recurrent costs at 10 percent of capital costs. 2.1.6 Summary cost-benefit calculations Table 5 below summarizes the costs and expected benefits from the project and shows the resulting base estimates for the rates of return and for the NPV, utilizing a discount rate of 10 percent. Table 5: Costs-benefits of reinforcing infectious disease surveillance (R$) Year Capital costs Incremental a Reduction in Benefits from Benefits from Net benefits costs costs morbidity mortality 1998 49,959,799 999,196 (32,986,197) 1999 49,959,799 1,998,392 516,454 5,223,754 12,232,590 (16,012,595) 2000 49,959,799 2,997,588 1,032,908 10,447,508 24,465,179 961,007 2001 56,204,775 4,121,683 1,549,363 15,671,262 36,697,769 11,564,763 2002 56,204,775 5,245,779 2,065,817 20,895,016 48,930,359 28,413,435 2003 56,204,775 6,369,874 2,582,271 26,118,769 61,162,948 27,289,339 2004 56,204,775 7,493,970 2,582,271 26,118,769 61,162,948 26,165,244 2005 - 7,493,970 2,582,271 26,118,769 61,162,948 82,370,019 2006 7,493,970 2,582,271 26,118,769 61,162,948 82,370,019 2007 7,493,970 2,582,271 26,118,769 61,162,948 82,370,019 NPV= R$116,989,779 IRR= 36% Under the assumptions made explicit in the above sections, the project exhibits economic internal rates of returns of 36 percent33. The combination of the public good nature of the investment and the fact that it is expected to yield a reasonably high economic rate of return makes a clear case for the project's desirability. 2.2 SENSITIVITY/RISK ANALYSIS This section tests the robustness of the rates of return calculation to changes in all the parameters retained in the base case. For the risk analysis, a Monte-Carlo technique is utilized which, in lieu of a numerical value, ascribes a probability distribution to the various parameters to simulate uncertainty - the output of the analysis is a confidence interval for the rates of return. Where appropriate, we find the switching point - i.e. the value of the parameter at which the NPV becomes positive. 2.2.1 Base hospitalizations, morbidity and mortality By using the average number of hospitalizations, confirmed cases and deaths over the period 1993-1997 as the base against which we calculate the potential effects of the surveillance system, we are grossly simplifying the problem of the counterfactual pattern of future hospitalizations, morbidity and mortality. As shown in Annexes 1, 2 and 3, each disease has a very different pattern34 of occurrence, and associated mortality and hospitalizations. However, we are in a position to gauge whether using the period 1993-97 as basis for estimating the effects of surveillance is a likely to result in an over- or an underestimation of the potential benefits, and Rates of return above the 10 percent threshold do not, by themselves, indicate that the project should be undertaken by the public sector. However, surveillance is clearly a public good and would be underprovided were it left to the private sector. 34 Modeling these patterns from the underlying complex of determining factors is beyond the scope of this analysis. factor this into the sensitivity analysis. Since the morbidity, mortality and hospitalizations are correlated to various degrees, we cannot simulate changes as if they were independent. The following simulations utilize triangular distributions whose upper and lower bounds are specified in table 6a, and correlation coefficients that are computed from past trends in hospitalizations, mortality and morbidity, and that are summarized in table 6b. Table 6a (triangular distributions) Lower & upper bounds as % of base estimates Measles [-0%; +100%] Poliomyelitis/PFA [-0%; +100%] n Diphtheria [-o%; +50%] Whooping Cough [-O%; +50%] Tetanus [-o%; +50%] Meningitis [-10%; +10%] Neonatal Tetanus [-10%; +20%] Hepatitis [-10%; +10%] Cholera [-0%; +200%] Rabies 10%; +10%] Leptospirosis [-10%; + 10%] Tuberculosis [-50%; +0%] Hansen's disease [-50%; +0%] Malaria [-10%; +10%] Leishmaniasis [-20%; +0%] Chagas [-50%; +50%] Schistosomiasis [-50%; +50%] Table 6b Correlation Coefficients Morbidity-Mortality Morbidity-Hospitalizations Measles 0.7523 0.9169 PoliomyelitislPFA 0.8962 -0.1286 Diphtheria 0.9931 0.9853 Whooping Cough 0.9812 0.7816 Tetanus 0.9569 0.9892 Meningitis -0.9002 0.5153 Neonatal Tetanus 0.9614 0.8913 Hepatitis 0.8490 0.6135 Cholera 0.9966 0.9917 Rabies 0.9999 0.4965 Leptospirosis 0.8149 0.8474 Tuberculosis -0.4270 -0.1111 Hansen's disease -0.6013 0.8686 Malaria 0.2881 0.5400 Leishmnaniasis 0.5152 0.8339 Chagas3I 0.5000 0.5000 Schistosomiasis3J 0.5000 0.5000 35 We assumed a correlation coefficient of 0.5 in the absence of reliable data. 36 Idem. Under the hypotheses described in tables 6a and 6b, the probability distribution of economic IRR and the NPV are summarized in figures 2 and 3 below. They show that the rates of return remain above the 1 0-percent benchmark even with even more conservative parameters. Figure 2 Forecast: IRR 5,000 Trials Frequency Chart 6 Outliers n24 ~~~~~~~~~~~~~~~~~~~~~~~122 a m. 915 -n CD, FRigure 3 Forecast: NPV 5,000 Trials Frequency Chart 15 Outliers 0 .023-I I-fll 11 Certainty is 90.00% from $53,416,667 to $117,083,333 2.2.2 Percentage hospitalizations, cases and deaths averted We next test the robustness of the rates of return calculations against changes in the effects of reinforcing the epidemiological and envirornmental surveillance systems on hospitalizations, confirm5ed cases and deaths. Once again, because changes in occurrence are coyelated with deaths and hospitalizations, we use the same simulation strategy as in section 2.2.1 above. Table 6b once again provides the correlation coefficients and table 6c the probability distributions. Table 6c (triangular distributions) Lower bound Base Upper bound Measles 0.5% 1.0% 1.5% Poliomyelitis/PFA 0.5% 1.0% 1.5% Diphtheria 0.5% 1.0% 1.5% Whooping Cough 0.5% 1.0% 1.5% Tetanus 0.5% 1.0% 1.5% Meningitis 0.5% 1.0% 1.5% Neonatal Tetanus 0.5% 1.0% 1.5% Hepatitis 0.5% 1.0% 1.5% Cholera 5.0% 10.0% 12.5% Rabies 5.0% 10.0% 12.5% Leptospirosis 0.5% 1.0% 1.5% Tuberculosis 5.0% 10.0% 12.5% Hansen's disease 5.0% 10.0% 12.5% Malaria 0.5% 1.0% 1.5% Leishmaniasis 0.5% 1.0% 1.5% Chagas 2.5% 5.0% 7.5% Schistosomiasis 0.5% 1.0% 1.5% Figure 4 Forecast: IRR 5,000 Trials Frequency Chart 15 Outliers .024 - 120 .00 10.0% 21.3% 32.5% 43.8% 55.0% Certainty is 90.00% from 18.3% to 45.5% Figure 5 Forecast: NPV 5,000 Trials Frequency Chart 6 Outliers .025- 126 .01~~~ -....-......-.. -.~~~~~~~.-*. . -~~..-.-........ ... ......94.5 i 013 ......... .... ........ ........ . ...........- . 63 0~~~~~~~~~~~~~~~~~ $0 $50,000,000 $100,000,000 $150,00000 $200,000,000 Certainty is 90.00% from $34,933,333 to $150,833,333 Figures 4 and 5 indicate that the project remains feasible even if the impact of the surveillance system upon mortality, morbidity and hospitalizations were to be only minimal (between 0.5 and 5 percent decrease). 2.2.3 Recurrent Costs We compute the rates of return and the net present value assuming that the incremental recurrent costs represent 10% of annual capital disbursements, and are cumulative and perennial. This drives the rates of return close to the 10% benchmark, but still slightly above it. The recurrent costs associated with the project clearly need to be monitored since they can offset the benefits of the project. Table 6d Recurrent costs I IRR NPV (R$ million) 10% of capital costs 11.3% 5.4 2.2.4 Valuing Productivity Finally, we check for the effect of valuing productivity at minimum wage on our results. When productivity is valued at 75 percent of minimum wage, the rates of return still exceed 10 percent. It takes valuing productivity at 70 percent of minimum wage for the rate of return to reach the 10 percent threshold. In other words, for the project to fail the economic feasibility test, the productivity of all the people affected by the project must be on average less than 70 percent of minimum wage, which is a rather extreme assumption. Table 6e Productivity IRR NPV (R$ million) 75% of minimum wage 14.1% 19.1 70% of minimum wage 10.0% 0.35 3. SUSTAINABILITY In this section we discuss the financial implications of the project for the major stakeholders. Ideally, we would proceed to discuss sustainability by estimating the incremental recurrent costs associated with the project, and gauge whether these can be absorbed by the Ministry of Health and other financing entities (States, Municipalities) with reasonable ease. The ease with which the costs can be absorbed would itself hinge upon the relative priority of public spending in the health sector, and upon the prospects of public finances, which in turn depend upon the growth. of the economy, and the revenue-collection strategy adopted by the govermnent. It is perhaps possible to carry out that kind of exercise in a meaningful manner for the short run (2-3 years). In the long run, it is very difficult to come up with any guarantee of sustainability - the best one can achieve is to gauge the degree of integration of the project activities within the financial fabric of the sector. 3.1 THE A VAILABILITY OF FUNDS AT THE FEDERAL LEVEL The health sector financing picture, in the absence of major shocks in the next few years, should look like table 7 below. CAS projections indicate an nominal increase in central government spending (including transfers) from R$131 billion in 1998 to R$139 billion in 2000, corresponding to a slight decrease relative to GDP, from 14.0 to 13.1 percent. Assuming that the proportion of total expenditures that is allocated to the health sector stays at its current level of 15.7 percent, then the nominal budget of the Ministry of Health should increase to 21.8 billion by year 2000. This assumption hinges on one crucial factor: that the government rapidly finds a viable alternative to the tax on financial transactions (Contribuicao Provisioria sobre Movimentacao Financeira - CPMF). This tax was earmarked to finance activities in the health sector, and is supposed to be provisional. In 1997, it accounted for a full 29 percent of resources ( or R$5.38 billion) allocated to the health sector. It was extended for 1998, and its contribution to health sector financing is expected to go up to 34 percent in 1998 (or $6.7 billion). As an alternative to the CPMF mechanism, Brazilian Congress is in the process of examining a tax reform bill that would earmark 30 percent of revenues for the health sector. There is an indication that this reform would also affect the states and municipalities, so that they will have to earmark a similar percentage of their revenues for spending in the health sector. Table 7 1996 1997 1998 1999 2000 GDP (R$ million) 753,823 838,231 891,134 967,174 1,062,766 Growth rate (lO) 3.1% 3.0% 0.5% 3.0% 3.5% Central Govt. Expend. (R$ million) 111,565 120,503 124,445 131,600 139,295 as % of GDP 14.8% 14.4% 14.0% 13.6% 13.1% MOH budget (R$ million) 14,377 18,804 19,502 20,623 21,829 as % of Central Gov. Expend 12.9% 15.6% 15.7% 15.7% 15.7% The project is expected to generate incremental recurrent costs that will have to be paid by the treasuries at federal, state and municipal levels. Since about 60 percent of the project funds will finance different subprojects from states and municipalities, it is difficult to estimate the consequent recurrent cost burden. We here estimate recurrent costs to be between 2 and 10 percent of the capital costs incurred in any particular year, and to be perennial and cumulative. Table 8 summarizes two scenarios, A and B, with incremental recurrent costs representing respectively 2 and 10 percent of capital costs. Table 8 (R$ million) 1998 1999 2000 2001 2002 2003 2004 Capital costs 34 34 34 39 39 39 39 Incremental recurrent costs - A 0.69 1.38 2.07 2.84 3.62 4.39 5.17 Incremental recurrent costs - B 3.45 6.89 10.34 14.22 18.09 21.97 25.85 The final step of this exercise is to confront the resources likely to be made available to the health sector with the financing requirements following project implementation. This is shown in table 9 for the two scenarios A and B for the period 1998-2000. Table 9 _ _ _ __ 1998 1999 2000 Expected additional resources allocated to the health sector at central level 697 1,818 3,024 Project incremental recurrent costs - A 0.7 1.4 2.1 Project incremental recurrent costs - B 3.5 6.9 10.3 Margin of maneuver- A 697 1,818 3,024 Margin of maneuver - B 694 1,812 3,014 It is quite clear from the above table that the additional resources likely to be made available to the health sector at central level are several orders of magnitude higher than the additional resources that will be needed to cover project-related recurrent costs. Even the incremental recurrent costs at their expected peak of R$25.85 million from the seventh year of the project life onwards, does not seem to be a matter of great financial concern. 3.2 TRANSFERS FROM THE FEDERAL TO THE MUNICIPAL LEVEL Two issues could theoretically tarnish the picture. The first is the fact that the above discussion does not take into consideration the level of government that will have to incur the project-related incremental recurrent costs. One could argue that while the federal level might be able to fund the activities generated by the project, these might actually have to be incurred by financially- constrained municipalities or states. We would then have to carry out an analysis of the ability- to-pay of the states and of the municipalities. However, the activities proposed within this project are the constitutional obligation of the federal government and will be funded from federal sources, although the implementing agency can be states or municipalities. In theory therefore the project should not increase the financial burden on the treasuries of states and municipalities as long as the federal level effectively transfers the funds. The second source of potential problem is the lack of integration of the financing of surveillance activities into the mainstream financing and procedural fabric of the health system, making them more dependent on and vulnerable to political vicissitudes. Recent changes in the health financing mechanism, however, indicate that surveillance activities are given high priority and that their financing is going to be ensured. The major change in the financing system that is currently occurring is the implementation of the Piso da Atenqdo Basica (PAB) - which is a system of financial transfers from the National Health Fund to the Municipal and State37 Health Funds covering basic health services. The new system is a departure from the former payment-for-procedures which in effect tended to discriminate against basic services in favor of "better-paying" tertiary care. The PAB is an attempt to create a financial mechanism to match the constitutional obligation of the Federal government to provide these basic services. The PAB is made up of one fixed and one variable part. The fixed part consists of a R$10 per- capita transfers of funds to the municipalities and covers such items as basic care, basic dentistry, family health, vaccination, community health education, pre-natal care, family planning, basic surgery, nutrition education, etc. The budget proposed for 1998 for the fixed part of the PAB is of the order of R$1.7 billion. The variable part of the PAB is specifically intended to give an incentive boost to sanitary, epidemiological and environmental surveillance, basic pharmaceutical care, family health, nutrition programs, etc. The transfers to municipalities and states for epidemiological and environmental surveillance will be the primary source of funds for VIGISUS-related activities. The 1998 budget for sanitary surveillance has already been set at R$42 million. The amount to be allocated for epidemiological and environmental surveillance, on the other hand, will be determined by the end of July. The first indications are that an amount of R$4. 16 million would be budgeted for 1998 for epidemiological surveillance activities; there is, as of April 1998, no indication of the proposed budget for environmental surveillance. The financial sustainability of the project will ultimately be determined by the actual budget transferred under the PAB, but it is already encouraging to see that funds will be made available explicitly for epidemiological and environmental activities. 37 The transfer of funds will transit through the State only for those municipalities that have yet to graduate to gestdo plena or the full management of their funds. Additional Elements of Analysis with reference to OPR Guidelines on Economic Analysis (a) What is the objective of the project? The objectives are: (a) to reinforce, streamline and increase the efficiency of the existing system of disease surveillance; (b) to bring down the prevalence of endemic diseases in the Amazon Region; (c) to improve the health status of the indigenous population. (b) What will happen if the project is undertaken? The expected project outcomes are: (a) a cost-efficient disease surveillance system that detects epidemics and triggers responses early on; (b) lower endemic disease prevalence in the Amazon Region; (c) better health outcomes in the indigenous population. (c) What will happen if the project is not undertaken? The benefits from previous disease control projects could be annihilated if re-emergence of disease is not detected quickly. The economic burden due to endemic diseases in the Amazon Region would remain very substantial. The health issues relative to the indigenous population would remain unresolved. (d) Is the project the best alternative? The project has several first-best characteristics: (a) surveillance is a public good which left to market forces would be underprovided; (b) the control of endemic diseases yields positive externalities: a pure market approach would lead to sub-optimal supply and demand; (c) there is no private sector solution to indigenous health concerns; and (d) endemic diseases disproportionately affect the poor, so that the project is equity- improving. (e) Are the project components separable? Yes. They are (a) an endemic disease control component in the Amazon Region; (b) a national surveillance system; (c) an indigenous health component. (f) If so, is each component justified? Yes. They accomplish important public health functions in three distinct areas. (g) Who are the winners and losers? No losers. Winners: the Brazilian population; the indigenous population; the inhabitants of the Amazon Region; the poor. (h) What is the project's fiscal impact? The project will create an additional recurrent burden of about R$26 million per year on the Federal budget. No immediate substantial burden on State and Municipal treasuries. (i) Is the project financially sustainable? Yes. The Government is expected to find a viable alternative to the CPMF (tax on financial transactions). The Brazilian Congress is currently examining a tax reform bill that would earmark 30 percent of revenues to the health sector. The recent introduction by the MOH of the Piso da Atencao Basica (PAB), a system of financial transfers from the federal level to the state and municipal health funds, indicates the government's strong commitment to public health, including epidemiological and environmental health surveillance. (j) Is this a risky project? There are medium risks associated with the project: (a) the changes in the surveillance system can become process-oriented (i.e. the focus is on the diseases notification system per se), and not result-oriented (i.e. to increase timeliness of response and sensitivity of reporting); (b) should the Government not find a plausible alternative to the CPMF, the burden of the incremental recurrent costs would be put upon States and Municipalities. Those States and Municipalities that are financially strapped might not be able to finance the recurrent costs. (k) What are the techniques for assessing whether the project is worthwhile? The disease control component will borrow from previous approaches that use well- established health protocols and that have proved cost-effective and successful in Brazil and in other public health programs worldwide. The surveillance component has been analyzed and shown to exhibit economic rates of return between 11 and 43 percent under conservative assumptions. 4. BIBLIOGRAPHY Akhavan D., "Cost-effectiveness analysis of malaria control and treatment in the Brazilian Amazon: lessons in strategy", Final report submitted to OED, World Bank, August 1997. Arredondo A., Lejeune L.Y., de Izaca E., Cost of diseases in Brazil: breast cancer, enteritis, cardiac valve disease and bronchopneumonia," Rev. Sauide Pu'blica, Vol. 29, No. 5, 1995, pp. 349-354. Choi K., Thacker S.B., "An evaluation of influenza mortality surveillance, 1962-1979, American Journal of Epidemiology, Vol. 113, No. 3, 1981, pp. 227-235. Dean A.G., West D.J., Weir W.M., "Measuring loss of life, health, and income due to disease and injury," Public Health Reports, Vol. 97, No. 1, 1982, pp. 38-47. Drumond M.F., Stoddart G.L., "Principles of economic evaluation of health programmes", Rapp. trimest. statist. sanit. mond., Vol. 38, 1985, pp. 355-367. Graitcer P.L., Burton A.H., "The epidemiologic surveillance project: a computer-based system for disease surveillance," American Journal of Preventive Medicine, Vol. 3, No. 3, 1987, pp. 123-127. Hinds W.M., Skaggs J.W., Bergeisen G.H., "Benefit-cost analysis of active surveillance of primary care physicians for hepatitis A", American Journal of Public Health, Vol. 75, No. 2., 1985, pp. 176-177. Marier R., "The reporting of communicable diseases," American Journal of Epidemiology, Vol. 105, No. X, 1977, pp. 5 87-590. Mills A., "Economic evaluation of health programmes: application of the principles in developing countries", Rapp. trimest. statist. sanit. mond., Vol. 38, 1985, pp. 368-382. Murray C.J.L., "Quantifying the burden of disease: the technical basis for disability-adjusted life years", Bulletin of the World Health Organization, Vol. 72, No. 3, 1994, pp. 429-445. Murray C.J.L., Kreuser J., Whang W., "Cost-effectiveness analysis and policy choices: investing in health systems," Bulletin of the World Health Organization, Vol. 72, No. 4, 1994, pp. 663- 674. Ostroff S., Hamilton D., "Review of the Brazilian Epidemiologic Surveillance System, Final report of CDC mission, Nov. 1997. Thacker S.B., Choi K., Brachman P.S., "The surveillance of infectious diseases," JAMA, Vol. 249, No. 9, 1983, pp. 1181-1185. Thacker S.B., Redmond S., Rothenberg R.B., Spitz S.B., Choi K, & White M.C., "A controlled trial of disease surveillance strategies", American Journal of Preventive Medicine, Vol. 2, No. 6, 1986, pp. 345-350. Thacker S.B., Parrish R.G., Trowbridge F.L. & Surveillance Coordination Group, "A method for evaluating systems of epidemiological surveillance, " World Health Statistical Quarterly, No. 41, 1988, pp. 11-18. Vogt R.L., LaRue D., Klaucke D., Jillson D.A., "Comparison of an active and passive surveillance system of primary care providers for hepatitis, measles, rubella, and salmonellosis in Vermont," American Journal of Public Health, Vol. 73, No. 7, 1983, pp. 795-797. Annex 6.1: Hospitalizations by Disease Cholera Poliomyelitis 50,000 1,400 1,200 400001 1.000 30,000 S 8o00 -1 20,000 6 600 1 ~~~~~~~~~~~400 - 10,000 200 U'Wt 0 )Q 0 0) riO riO riO d oo co)c) coco0) 0) 0)0)0D00)0)0) Meningitis Hansen's Disease 35,000 15,000 30,000 25,000 - 10,000 20,000 5 15,000 l l. . 10,000 / 0 <9oi~~~~~~ ~ 69ofi 9o 9s 9 92,>;;<,l al n0i0figE 5,000 6 Tuberculosis Rabies 20,000 120 15,000 100 10,000 - 60 5,000 -40 1° , I I , , , 9 9° 9999 O g 9 9 9920 Diphtheria, Whooping Cough & Tetanus Neonatal Tetanus 5,000 80 4,000- 50 i 3,040 40 30 2,000 20 1,000 -10 N41 Cbl b" 4P S Leptospirose Vlral Hepatitis 5,000 25,000 4,000 20,000 3,000 ~~~~~~~~~~~~15,000 2,000 10,000 5,000 - 1,000 _ _ _ _ _ _ 1991 1992 1993 1994 1995 1996 1997 ,00 10 qb .e Ik Measles Malaria 14,000 60,000 12000 ooo . . . .50,000 . 10'000 40,000 \ 84000 30,000 _ Leishmanilasis Dengue 6,000 2500 5,000 2000 4,000 1500 3,000 10,000 21000 2500 - 1,000 _ _____ _____99___ __ ____ _ ___ ___ ___ ___ ___ ___ ___ ___ _ .0 I 01 Annex 6.2: Mortality by Disease Cholera Tuberculosis 500 8,ooo 400 8,000 3001 4,000| 1001 2,0001 Viral Hepatitis Rabies 1,000 200 800 150 400 100- 200 ___________________ 50 01, LaeismniasDisMeaseletsioes 400 200 20 200 -4,000 150 ....---...3,000 - 100 , , 2,000 - , c- _c,c 50 9OK 9Ob 9O« s99 699 6995 8 9S9 9OD6N 1,000 q~~~~q;b~~~~~~~%~~~~ ~~q Neonatal Tetanus Diphthena, Whooping Cough & Tetanus 800 +oDitt 60 72,000 l ~Coqhe 1,5000 200 500s D^ Acute Poliomyelitis Meningitis 400 ~~~~~~~~~~~~~~~~~~5,00 4,00 300~~~~~~~~~~~~~~~~~~3 -100 1,000 CO____________'A__I__________ 0, 1Zj, *i. *o. ,q c N.), f, , .'bl , ,l ,P ,P ,bI ,q I ,, Malaria 1,500 1,000 500 19W ~ ~ ~ ~ 98 1980~~~~~~~~~~1801W18 1982 1982 1982 1982 1984 1984 198498 1986 ~ ~ ~ ~ ~ ~~~~18 1961986 1986 1988 1988 4- 1988 1988 1990 1990 19W 1W990 192 1992N 1990 1992 1994 1994 1994 1994 1996 1996 1996 1996 19W~~~~~~~~~~~~~~~.J 19W ~~~~~~198 1980 1982498 1986 ~ ~ ~~~~~~~~1921984 1986 19844 t- 1988 9 1988 19018618 1990 1 a.~~~~~~~~~~~~~~~~~~~~~~~~~~18 19W m 1986 C992 , ' 1992 1 i4 ! 9~88 1988 1994 rn - IL 1996 w 0 ~~~~~~~ ~~~~~~~~~1990 w1990 1996 1992 -1992 p ~~~~~~~1996 1996 0 0 m Leptospirods 6000 Meases 400 1400 0 _ _ _ ___ 120000 3000 100000, 1000 6000. 0. 4000 20000 0 Malaria Tetanus 600000D 50ODO A o- so 40000DO. 3000 30000W - 2500 200000 2000. _ UT UMno Ac2dermt 100ODO 15 00 T6tu,o Neonata 0 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _1000 O . . . . . . . . . . . 500 , Meningits Tuberculods 30000 20000 /0000. 100DO 5400DO 20 2000 0 g i | | g g ffi | O i,,,, I I I I I I I I I I I PollomyoltlsWPFA 1200 1000 400 200 -ISI1 , Human Rabies 150fx 100 -- 50 .. I f Annex 7 Brazil - Disease Surveillance and Control Project (VIGISUS) Control of Endemic Diseases in the Amazon Region VIGISUS will provide technical, human and material support to help expand the surveillance and control of endemic diseases in the Amazon Region. This is justified because of (i) the high incidence of endemic diseases; (ii)the large size of the geographical extension of the region; (iii) the limited development of its health services infrastructure; and (iv) the effect of frequent population migrations on disease incidence in an environment which is ecologically propitious for disease transmission. Five diseases -- malaria, hepatitis B, tuberculosis, leprosy, and leishmaniosis (both American and Visceral) -- will be targeted by the VIGISUS program. Their selection is based on: (i) their epidemic potential; (ii) their high case-fatality rate; and (iii) the availability of low cost control measures. Definitions. An endemic disease is a disease which is habitually present (frequent) within a specified area and/or population group, over time. An epidemic is an unexpected increase of the presence (frequency) of a disease within a specified area/population, during a given period of time. An emerging disease is a disease whose incidence in humans has significantly increased within a specified area/population, over the past two decades. A re-emerging disease is a disease that has reappeared after a significant decline in its incidence, within a specified area/population group, over a long period of time. Malaria Malaria is caused by the infection of any of the four species of Plasmodium which infect humans. These are P. falciparum, P. Vivax, P. malariae and P. Ovale. All circulate in the Americas, except the last one. Infection is commonly transmitted by the bite of a female Anopheles mosquito, which in most species bite at dusk and during the early evening hours. Despite considerable efforts to control malaria, it is still the most common disease in the tropics. It threatens about 40 percent of the world's population, undermining the health and welfare of families, endangering the survival of children, debilitating the active population and straining both countries' and people's scarce resources by excessive public health costs, low productivity and impaired growth. Despite Brazil's successful efforts to curb the incidence of the disease, there were still 400,000 cases in 1996. The great majority of those are concentrated in Amazon Region. Contemporary approach to malaria control. The goal of most countries where malaria is endemic is to prevent mortality and reduce morbidity and social and economic losses through the improvement and strengthening of national capabilities. The four elements of control are: (i) disease management through early diagnosis and prompt treatment; (ii) implementation of selective and sustainable preventive measures, including vector control; (iii) malaria mapping and disease surveillance to permit a selective approach, to identify epidemic risk, and to monitor program progress; and (iv) strengthening of local capacities in basic and applied research to permit regular assessment of malaria situation in the country. Activities to achieve quality control measures. The main activities are: (i) human resources development and management; (ii) adequate pharmaceuticals policy to assure supply of diagnostic and treatment services as well insecticide spraying;(iii) effective information systems; (iv) promotion and development of operational research; (v) effective managerial capability and logistical support and; (vi) social participation and intersectoral and community interaction. Specific Strategies for stratified areas of risk. In high risk areas, the strategy consists of: (i) expansion of the diagnosis and treatment capability, in remote health posts and antimalarials supply; (ii) prevention of transmission through protective and preventive measures for individuals, families and communities; and (iii) motivation and involvement of the population at risk in the decision-making process at the local level. Moderate and low risk areas. In moderate and low-risk areas, the strategy consists of: (i) assuring that all health service units are capable of early diagnosis and treatment of all malaria cases; (ii) reducing and eliminating vector breeding sites by means of environmental sanitation by community action; (iii) undertaking selective vector control; and (iv) providing social education and health promotion for the affected communities. In areas of frontier development, such as the Amazon, traditional control activities are extremely difficult, and case management, i.e. early diagnosis and immediate treatment, becomes the priority. It has proven to be a cost-effective intervention for reducing the burden of malaria and is now considered the center-piece of any malaria control strategy. The aim is to ensure access to health services in order to eliminate death from malaria and to reduce the severity and duration of illness associated with it. Vector control still has an important role, but it is now based on the epidemiological stratification by municipalities and by community, according to levels of risk of malaria transmission should the common practice. Tuberculosis Tuberculosis in the World. The magnitude of the global tuberculosis (TB) epidemic is staggering -- its reemergence led WHO to declare a Global Health Emergency in 1993. With an estimated 3 million deaths each year, it is the most deadly communicable disease, although it is preventable and curable. Tuberculosis afflicts all age groups and populations in all regions -- although most affected are persons in their productive adult years. Ninety five percent of the global TB burden is shouldered by developing nations. Without treatment, 50 percent of persons ill with the disease will die within 2-5 years. TB kills more girls and women worldwide than all maternal causes. TB is caused by the mycobacterium M. Tuberculosis, which in most cases attacks the lungs. Infection is transmitted from persons with active pulmonary disease to other persons usually via coughing and sneezing. One infectious case is likely to transmit the infection to 10-15 persons, usually close contacts, within one year alone. Over one third of the world's population is infected by M Tuberculosis. Only 10 percent of infected persons will go on to develop active and debilitating disease. The figure is far higher in persons whose immune systems are compromised. HIV+ persons are over 30 percent more likely than their HIV- counterparts to develop disease once infected. TB is the principal cause of death arnong HIV-infected persons in Africa and will likely become so in Asia and high TB-prevalence areas of Latin America and Europe as the HIV/AIDS epidemic becomes more generalized. 50-80 percent of cases of active disease occur during the first two years after infection, but disease can develop decades after initial infection. The Bacille Calmette-Guerin (BCG) vaccine is recommended for all newborns to serious forms of tuberculosis in children, but has shown little efficacy is preventing transmission and infectious disease. In TB control, treatment of infectious cases is the most effective prevention tool. TB symptoms are varied, but principally consist of productive chronic cough, weight loss, fever, and night sweats. Microscopic examination of TB bacilli in sputum is the most important diagnostic tool. Additional tools such as sputum culture and X-ray are utilized in detecting less infectious cases. In moderate and high TB prevalence countries, sputum-smear positive cases represent over 60 percent of the TB burden. Sputum-smear negative pulmonary cases are less infectious but still pose a public health threat. Extra- pulmonary cases represent 10-20 percent of the burden. Treatment of detected cases consists of 6-8 months of therapy with 4-6 drugs (isoniazid, rifampicin, pyrazinamide, ethambutol, streptomycin, thiacetazone). This treatment can be provided on an ambulatory basis within primary health services or in the community. The treatment is over 98 percent effective in persons not harboring drug-resistant disease -- and leads to the swift elimination of infection. The critical challenge is to ensure that patients complete the long treatment although symptoms disappear within several weeks. Retreatment regimens are generally of 8 months duration. However, for persons prescribed insufficient drug regimens or who take them inconsistently or fail to complete, drug resistance can develop. This poses a significant worldwide threat to TB control and to patient survival -- as treatment for multi-drug resistant disease is prohibitively expensive in most countries and is less efficacious. Direct-observation of treatment by a health worker or volunteer has proven highly effective in increasing smear-conversion and treatment completion. Less than 60 percent of tuberculosis cases are detected and treated worldwide each year -- of those treated most do not receive treatment to cure -- although this situation is beginning to change. WHO now recommends worldwide application of a proven cost- effective public health strategy, DOTS (Directly-observed Treatment Short-course) to control the disease. It consists of political commitment to a national control program, case detection principally through smear microscopy of persons presenting at health services, standardized and directly-observed treatment for infectious cases, a secure system of drug supply, and a recording and reporting system which documents patient progress and program effectiveness. Nearly 100 countries have adopted the strategy, and within each Region there are countries achieving treatment success rates over 80 percent and rapidly improving case detection. Cost-effectiveness studies in high-prevalence countries have shown that the DOTS strategy is among the most cost-effective health interventions available: costing $20-25 per death averted when provided on an amnbulatory basis -- or US$ 1-4 per Disability- adjusted Life Year saved. In middle-income countries, these costs will increase principally due to greater labor costs but remain among the most cost-effective interventions available. Tuberculosis in Brazil. Tuberculosis is a major public health threat in Brazil. In 19951, 91,013 new tuberculosis cases were notified (58.6/100,000). The smear-positive case rate (infectious cases) is higher in the Amazon Region than in any other region, but 39 percent of all cases are reported by Rio de Janeiro and Sao Paulo. Reported incidence has surged after a declining trend in the 1980s. Registered TB deaths have also increased with 5,977 deaths registered in 1994. The Ministry of Health and WHO/PAHO estimate that true incidence is approximately 120,000, signifying 25 percent under-reporting. The HI V/AIDS epidemic is estimated to have increased tuberculosis incidence by 10 percent a year. Other factors, including economic factors and obstacles in public health service delivery may also contribute to rising incidence. Brazil has a long history of tuberculosis control and research during this century. It was among the first countries in Latin America to adopt rifampicin-based short-course chemotherapy in the 1970s. Smear-microscopy is the predominant diagnostic tool although still too many patients are diagnosed without smear examination, and too few health centers are pursuing case detection and treatment. The network of laboratories performing these exams and ensuring quality control urgently requires strengthening. This will be undertaken under the VIGISUS project. Treatment is ambulatory and drug supplies have been secured by the Ministry of Health for all detected cases. Direct observation of treatrnent (DOT) is not pursued except in a few local services. DOT is recommended by WHO and other international agencies as a ' fnal data not yet available for 1996 cost-effective treatment to improve cure rates and thereby reduce disease transmission and mortality. The reported treatment completion/cure rate in Brazil of approx. 70 percent (for cases detected in 1995) is well below the year 2000 global target of 85 percent, and below many neighboring countries (Bolivia, Chile, Peru, Uruguay, Venezuela). Drug-resistant disease is limited, as documented by a recent national anti- TB drug resistance survey. This is likely attributable to the use of fixed-dose combination antibiotics. States and municipalities have long played the central role in case detection and treatment, and are now receiving funds, via contracts with the MOH, to pursue an emergency plan for intensified TB control activities in priority municipalities including surveillance, training and supervision. Additional funds will be provided under the VIGISUS project. In 1998, the MOH will pursue a new plan to demonstrate innovative practices to increase the number of health centers, posts and community health workers in case detection and in directly-observed treatment in the states of the Center-West This work should help demonstrate the feasibility of improving TB control rapidly in Brazil and the utility of simple treatment and lab registers in improving reporting and local analysis of service quality. It will be the first time in Brazil that tuberculosis control will be significantly supported by Bank financing. Project Objectives. The project objectives are to: (i) develop technical capability of local health services to identify, detect, diagnose and supervise the treatment of tuberculosis patients; (ii) implement case-finding programming at all levels of the health services facilities; (iii) identify at least 90 percent of existing hidden prevalent cases of tuberculosis; (iv) ensure the complete treatment of at least 85 percent of all detected cases of tuberculosis-infected individuals; and (v) develop a health promotion program to gather political, economic and community support for the tuberculosis program. Activities to be developed. The project will help: (i) rebuild the capacity of the public health laboratory system to diagnose tuberculosis; (ii) train community health workers to improve the quality and efficiency of the tuberculosis control activities; (iii) review and improve establishment of priorities at the municipal level of Amazon Region; and (iv) implement the supervised treatment to high risk groups. Hepatitis B Hepatitis B is a viral infection caused by a DNA virus, VHB, which is estimated to have a human circulation based on 300 million carriers world-wide, two billion people infected and 1-2 million deaths per year. Clinical symptoms. Around two-thirds of the cases do not show symptoms at adult age or look like a flu syndrome. The disease is transmitted at acute stage, with or without symptoms. Around 90 percent are cured, one percent die at the acute phase, and the difference become chronic carriers. Some of the carriers do not have symptoms, others evolve to the chronic stage. All of the carriers can transmit the disease, which can also to evolve to cirrhosis or cancer. More than 80 percent of primitive liver cancers are related with VHB that, after tobacco, is the most important human carcinogen. In Brazil, hepatitis B prevalence varies greatly from region to region. The western part of the Northern region has prevalence rates which are very high, ranging from 5.1 to 16.7 percent of the general population. By 1991, it was estimated that somewhere between 300,000 to 500,000 HBV carriers were circulating in the Amazon Region of Brazil. The incidence rate for acute hepatitis in the Amazon ranges from 65.7 to 131.1 per 100,000 population. Recently, the treatment of this disease and its consequences have been costing around US$31 million to the SUS per year. In 1990, despite Brazil's 7.4 percent of deaths efforts in the state of Amazonas were attributed to hepatitis-related causes, exceeding by far the proportion for malaria (3.3 percent) which used to be the most important disease in the Amazon Region. Treatment. There is no specific treatment. At an acute phase support treatment should be provided and at a chronic stage, the alfa interferon helps strengthen the immunity system. Prevention. In countries with high endemicity, universal immunization should be provided to all newborns. In countries with moderate or low endemicity, immunization should be provided to high risk groups (such as health professionals, homosexuals, sexual workers, immunodepressed, drug users and mental disorders patients). Universal immunization for newborns and or adolescents should also be provided. Prevention after virus contact includes: (i) blood testing; (ii) direct administration of IgHB as soon as possible, never after 48 hours; and (iii) a first dose of the vaccine (the total immunization process will be based on results of blood tests). Activities to be developed by the project. The project will help: (i) develop and launch a large scale immunization program for hepatitis B vaccine; (ii) finance all three (management/program operation/health education) human resources programs; (iii) train mid level managers technical personnel and health workers, applied epidemiology; and (iv) undertake a mass media campaign for immunization acceptability. Leprosy (Hansen's Disease) One of the oldest diseases known to humankind, leprosy is an infectious disease caused by Mycobacterium leprae. The host response to this infectious agent depends on the cellular immune mechanism. The clinical spectrum of leprosy varies from a single benign hypopigmented skin patch that may heal spontaneously to widespread damage to nerves, bones, eyes, muscles, and kidneys. The onset of leprosy is usually gradual, and the first signs may not be apparent for quite some time after infection. The average incubation period is estimated to be two to four years. Patients rarely die of leprosy. The mode of transmission is not known with certainty. Two widely-accepted modes are direct skin-to- skin contact and droplet dispersion, but there is still no clear-cut evidence to support their role. As no specific primary preventive measure has been devised, the main strategy must be early diagnosis and adequate and regular treatment. The Amazon Region accounts for 35 percent of the total cases of Hansen's disease in Brazil. i.e. three times the national prevalence rate. Historical and cultural aspects of the wild colonization of the Amazon Region are the main causes for this high prevalence of the disease. In the Amazonas state, the prevalence is 31,16/100,000 inhabitants. However, there are states such as Amapa, Roraima and Tocantins with a low disease coverage rate The case management strategy includes: (i) treatment of leprosy with multidrug regimens (rifampicin, dapsone, and clofazimine, doses depending if paucibacillary or multibacillary leprosy); (ii) treatment of complications of leprosy (nerve damage, ulcers); (iii) reconstructive surgery; and (iv) psychological therapy and rehabilitation. Early diagnosis is crucial, thus early case-finding activity must be promoted by leprosy control program. Passive case finding is greatly improved by increasing accessibility of health care and health education. Active case finding usually involves screening of school children, contact surveillance, and mass population screening activities. Because often control programs employ paramedical workers for leprosy diagnosis at the village level, simple diagnostic criteria are needed. Specific diagnosis reduces waste in drugs. Two types of delivery are in-house treatment and stationary clinic treatment. In-house treatment results in high coverage, but is very costly, especially when supervised, because treatment with rifampicin and clofazimin must be given at least once a month. Because of the social stigma attached to leprosy, primary health care workers are often not highly motivated to work with leprosy patients. Thus training of primary health care workers is important. Project Specific Objectives. The project objectives are to: (i) decrease the percentage of cases not reported; (ii) increase the effectiveness of the treatment; and (iii) improve the technical and management training of all professionals working on this disease. Activities to be developed. The project will help: (i) train health professionals about recognition of diagnosis and treatment; (ii) improve coverage and quality of diagnostic and treatment services; (iii) promote and develop operational research; (iv) develop a monitoring system for all patients under treatment; and (v) promote social participation and intersectoral and community interaction. Leishmaniosis. Leishmaniosis, a dreadful protozoal2 disease, is transmitted through the biting of infected sand flies (phlebotomies). Main reservoirs include dogs and rodents. The main manifestations are ulcerating lesions which may be single or multiple, involving the whole skin and mucocutaneous3 tissues (cutaneous leishmaniosis - LTA). Visceral 2minute animals, often parasites of man and animals involving both typical skin and mucous membrane involvement, especially of the liver and the spleen, if untreated, is usually fatal (visceral leishmaniosis or Kala-azar). Both forms of the disease exist in vast areas of Brazil, and in all the Northeast Region. In the last decade 27,855 new cases of LTA were reported in Brazil, from which 60 percent were in Amazon Region. Para, Roraima, Maranhao, and Tocantins were considered priority states to conduct LV control activities. Activities to be developed. The project will help: (i) develop human resources; (ii) assure an adequate supply of diagnostic and treatment services; (iii) improve the information system so as to devise control strategies based on risk by specific geographical area; (iv) develop operational research; (v) undertake health promotion activities; (vi) increase periodic screening of dogs; and (vii) improve insecticides spraying. Annex 8 BRAZIL - Disease Surveillance and Control Project (VIGISUS) Organization and Legal Framework of the FNS Legal History. The Brazilian epidemiological surveillance system is more than 20 years old. It was created by law 6259 of October 1975 that gave the power to the Ministry of Health to organize an epidemiological surveillance system, a national immunization program, and establish norms relative to compulsory notification of diseases. In May 1976, Portaria (ministerial resolution) 161 created the Superintendence of Public Health Campaigns (SUCAM), a semi-autonomous agency, in charge of disease surveillance and control. In August 1976, decree 78.231 provided the operating principles of the epidemiological surveillance and control system, defining four hierarchical levels: (i) the federal level; (ii) the regional level (groups of states); (iii) the state level; and (iv) the health unit (i.e. the epidemiological surveillance unit). The federal role is defined as that of: (i) establishing norms; (ii) supervising execution by lower levels; (iii) analyzing and disseminating epidemiological surveillance data to be used for disease control; and (iv) providing technical assistance to lower levels. As one goes down from the federal to the local level, the function of execution increases, while that of supervision decreases. Two observations can be made. First, these roles were well defined in the law and are valid today as can be seen in Annex 9. The problem that occurred over the years is that SUCAM, and later the FNS, increasingly took on an executive function which would have better been left to the local levels. Second, there is no mention of the role of municipalities in the 1975 law and in the 1976 decree. That would come twelve years later in the 1988 Constitution that states that all public health services are to be provided by the municipalities with the technical and financial help of the federal government and the states. On April 16, 1991, Decree 100 created the National Health Foundation (FNS), a public foundation linked to the Ministry of Health (MOH). It took over SUCAM's functions. Organizational Structure. The present organizational structure of the FNS is shown at the end of this annex. Disease surveillance is performed by the CENEPI (National Center for Epidemiology) and disease control is conducted by the DEOPE (Operations Department). CENEPI includes a unit that coordinates the national epidemiological surveillance system, and one that is in charge of the national system of public health laboratories (COLAB). The DEOPE comprises several units responsible for the control of vector-borne diseases such as malaria, Chagas, dengue, leishmaniasis, and others; for the provision of health care to Indian communities; and for sanitation. The FNS has offices in each of the 26 states and in the Federal District, which are responsible for the implementation of surveillance and control activities at the state and municipal levels. As of April 1997, the FNS had a staff of 42, 415. Most of the staff (i.e. about 98 percent) are located in the field and report to the Regional Coordinating Offices (Coordenav5es Regionais), while 900 work in Brasilia. The great majority of the professionals (about 33,000) are assigned to the control of vector-borne diseases (e.g. malaria in the Amazon region, schistosomiosis and dengue in the Northeast, Chagas disease in the West Central region). About 400 professionals provide health care to the Indian communities, and about 200 are assigned to the Institute Evandro Chagas, a research facility focusing on the study of tropical diseases prevalent in the Amazon Region, and the Primate Center. Performance of the FNS. The FNS (as its predecessor, SUCAM) has a positive track record. It has created and implemented a disease surveillance and control system and has had significant success in the prevention and control of disease transmission. It has been characterized by the strong loyalty and dedication of its staff, and its remarkable field experience and work discipline. It has been successful in implementing two Bank- financed projects: (i) the Amazon Basin Malaria Control Project (loan of US$99 million); and (ii) the Northeast Endemic Disease Control Project (loan of US$109 million). The Implementation Completion Report of the Amazon Basin Malaria Control Project states that: "with better-trained health care providers and a more efficient management structure in place, future health operations in Brazil should be implemented with fewer obstacles and also more quickly." This is certainly a positive track record; and yet the government has started to reform the FNS. Why is that? Reasons for Reforming the FNS. The decentralization of the FNS is part of the restructuring of the MOH, which is itself part of a broader reform whereby the Government, through the Ministry of Administration and State Reform (MARE), has undertaken to restructure public institutions and make them more efficient. A technical group (Grupo Tecnico de Restruturaqdo e Qualidade) composed of representatives of the MARE, the MOH, and the University of Sao Paulo is helping the MOH implement a Program of Restructuring and Efficiency of the MOH. The plan for the decentralization of the FNS is laid out in an October 1997 MOH document entitled Fundavao Nacional da Saude - 0 Ministerio da Sauide em movimento de transformaado (FNS - The Ministry of Health in transformation). The main reason ifor decentralizing the FNS is that, in principle, health services (in this particular case, disease surveillance, prevention, and control) may be provided more efficiently by the local level which is in direct contact with the needs of the population. Over the years, the FNS has taken too much of an executive role, whereas it should be a normative and supervising agency. Its staff has become too large and is difficult to manage. It owns buildings and facilities that would be better managed at the state and municipal level. As a result the government has already started to decentralize: (i) staff, (ii) facilities; and (iii) financing. Decentralization of Staff. The staff of the FNS working in the Coordenaqtoes Regionais is being transferred to municipalities (and states) through agreements between the FNS and the respective municipality. The FNS will continue paying the staff, thus avoiding an immediate fiscal burden for the municipality. Upon retirement, the staff will not be replaced by the FNS, and it would then be the responsibility of the municipality to hire a replacement. This strategy which has already started to be implemented. This transfer will be gradual and is expected to take about 7-10 years. It is a prudent strategy which does not burden the municipalities financially, and which allows them to gradually strengthen their institutional capacity. At the end of this process, it is expected that the FNS staff would be reduced to about 3,000, responsible for the financing, regulation, monitoring and supervision of the disease surveillance and control system implemented by the states. The FNS would also retain the direct management of catastrophic outbreaks, and the provision of health to indigenous communities, as the latter is a federal responsibility under the Constitution. Decentralization of Facilities. The FNS used to own 823 health facilities (health posts, health centers, and unidades mistas, which are small regional hospitals with 10-20 beds each). Of these it has already transferred 53 percent to municipalities and plans to transfer the rest over the next few years. The FNS still owns facilities in 246 municipalities, which represents less than 5 percent of all municipalities in Brazil. Before each transfer, the FNS assesses the receiving municipality's capacity to operate and maintain the facility. Some other facilities and departments have also been transferred during 1996 and 1997. These include the Manaus Nursing School (transferred to the Federal University of the Amazon state), and the DATASUS, which processes all the country's hospital discharge and ambulatory consultation forms used for payment of health services (transferred to the MOH). Decentralization of Financing. To accompany the transfer of responsibility to the municipalities, the federal government has designed a financial transfer system under the Norma Operativa Basica (Basic Operational Norm) No. 96. This norm has created a table of prices to be paid to municipalities for each surveillance or control procedure undertaken. For example, the collection of blood from a domestic or stray animal for the diagnosis of visceral leishmaniasis is worth US$0.03; the control of the Aedes aegypti (the vector mosquito for dengue) is worth US$4.00 per insecticide application. Under this system, disease surveillance and control actions will be financed through the normal SUS system, just like the rest of health procedures. Municipalities will bill the MOH for each procedure and will be paid up to a monthly ceiling. During 1998, the MOH plans to transfer US$1.7 billion for basic health care, including epidemiological and environmental surveillance. Legal Framework of Decentralization. The fundamental principles of decentralization were instituted by the Constitution (article 198) and by law 8080 of September 19, 1990. The legal instruments to implement decentralization consists in agreements (Termos de Convenio) between the FNS and municipalities. As mentioned earlier, specific agreements for the transfer of health facilities and staff have already been entered into between the FNS and a number of municipalities. Agreements will also be developed for the transfer of Coordenag6es Regionais to the states. Legal Status of FNS. There are three scenarios regarding the future of the legal status of the FNS. The first is that the FNS would maintain its present status of Foundation. It is a possible, but unlikely scenario. The second scenario is a radical one that would involve the closure of the FNS. Should that happen, the field staff would be transferred to municipalities and states as is already contemplated under whichever scenario, and the central staff would be transferred to the MOH. The functions of regulation, monitoring, and supervision carried out by the FNS central staff today are essential in any system and would have to continue to be carried out, whatever the legal figure. Finally, the third scenario is the transformation of the FNS into an "Executive Agency". In that case, it would achieve greater administrative and financial autonomy, and would enter into management contracts with the MOH linking financing with expected results. In March 1998, the third scenario appeared to be the likeliest, but no decision is likely to be taken during the present election year. That does not affect the processing of the proposed VIGISUS project as there is clear consensus in the government and the MOH on the overall decentralization strategy and on the roles of the federal, state, and municipal levels regarding epidemiological surveillance and control. Annex 9 BRAZIL - Disease Surveillance and Control Project (VIGISUS) The Brazilian Epidemiological Surveillance System Definition. An epidemiological surveillance system is a system that collects, analyzes, and disseminates information and recommendations to help prevent and control public health epidemics and problems. Sources of data for epiderniological surveillance generally include: * compulsory notification of cases * diagnoses from doctors * death certificates * laboratory results * blood bank registers * investigations of cases and epidemics * location of vectors and reservoirs * use of biological products (e.g. drugs, vaccines, insecticides) * newspaper articles The Brazilian System. The Brazilian disease surveillance system' is designed to operate in a similar fashion to that of the United States. There is a list of nationally notifiable conditions which are all infectious diseases; states and municipalities may choose to supplement the list of conditions based on local needs. Disease notifications are made to municipal health departments by physicians, hospitals, or laboratories. Many municipalities have devised their own notification mechanisms (i.e. cards, telephone, etc.). The municipalities have primary responsibility for completing case notification cards, investigating reported cases and completing case investigation forms, and investigating and controlling disease outbreaks. The municipalities may also collate and analyze surveillance data. Municipalities forward case notifications/investigation forms to the state health department. Some states use regional offices which act as a layer between the municipality and the central state surveillance unit. In these instances surveillance data are submitted to the regional unit, which then may collate the data and forward to the central state unit. These regional units may function as a resource to the municipalities. The state health department collates and analyzes the data, and may 1 This annex is based upon a report prepared by Steve Ostroff and Douglas Hamilton of the Centers for Disease Control after a mission to Brazil in November 1997 perforn analytic epidemiological studies. The states collate the data and then forwards it to the appropriate national agency. There are three principal national health data collection systems which work through these channels2. These are: (i) Live birth data - known as SINASC (ii) Notifiable disease data - known as SINAN; and (iii) Mortality data - known as SIM Each system has standardized forms (death certificates, birth certificates, and disease notification forms) which have been incorporated into computer-based systems. Most of the state health departments use the SIM and SINASC systems, although some have not yet fully implemented them. SIM and SINASC data are submitted to DATASUS in Rio de Janeiro; SINAN data go to CENEPI in Brasilia. Very few jurisdictions are able to transmit data electronically. Municipalities send data to the regional or state health department by paper forms or on computer disks. Most states send data to the national agencies on computer disks. SINAN contains standardized investigation forms for each of the 41 nationally reportable diseases'. These data are all eventually submitted to the national level. The data for each of these diseases is submitted to the SINAN coordinator in Brasilia, but the states are also required to submit the data separately to each of the 41 programs that have responsibility to manage the disease. There are additional data systems managed by FNS. These systems include hospital discharge databases (SIH/SUS) and ambulatory care databases (SIA/SUS). These are primarily designed for reimbursement purposes to the municipalities, but have been viewed as supplemental surveillance data sources; substantial energy has gone into looking at them for such purposes. There are between 5,000-6,000 municipalities in Brazil. They vary in size from several thousand persons to the major population centers of Rio de Janeiro and Sao Paulo. They also vary greatly in their data collection, disease investigation, and outbreak response capacity, and in trained personnel. Due to these factors, municipalities may of necessity cede some of these responsibilities to their regional 2 in addition, two other systems (SIH-SUS and SIA-SUS) provide data on hospital discharges and ambulatory care, respectively. 3 The World Health Organization (WHO) proposes two criteria for the inclusion of a disease in the surveillance list: (i) the existence of an active programn to control the disease, if possible with established objectives in terms of incidence and prevalence; and (ii) the assurance that the notification of a case or an epidemic will result in investigations to find out the cause or state counterparts. The states vary in size from less than 300,000 persons to more than 34 million and also have considerable differences in capacity. Access to laboratory diagnostics is highly variable in Brazil. In some areas, most notifiable disease case reports are based on clinical impression or non-specific laboratory findings, such as gram stains of cerebrospinal fluid for meningitis cases. Major municipalities may have access to more sophisticated laboratory diagnostics. But even in the major population centers, the bulk of diagnostic work in municipal and state public health laboratories is for clinical purposes (i.e. clinical chemistries, blood counts, urinalysis) and not for reference or public health diagnoses. Despite this, many state public health laboratories are able to diagnose diseases such as dengue, perform food-borne pathogen subtyping, isolate M tuberculosis, and perform antimicrobial susceptibility. These laboratories may also forward materials to the national reference laboratories when necessary. The national labs also perform quality control and provide diagnostic reagents to the state and municipal facilities. The Brazilian system of public health laboratories is described in Annex 10. There is currently no national system for recording laboratory findings similar to the role of SINAN in disease reporting. The laboratories at the various layers of government either have developed their own computer systems, or they continue to record results by hand. Computer systems currently in use are incompatible with the SINAN system, and laboratory data must be manually reentered for incorporation into SINAN. Outbreak investigation and initiation of control measures require special expertise. The municipalities have primary responsibility in this area, but may draw upon resources from other levels of the system when* necessary. Municipalities questioned about their experience with outbreak response during visits to a number of locations showed highly-variable levels of satisfaction with regard to state support. Similar sentiments were expressed by states with respect to the national level. Health facilities produce summary reports of collected data. These reports are often very detailed, but in many instances lack critical information to properly interpret the findings (i.e. population data, maps, etc). It is not clear who the target audience is for these reports, or how they are disseminated. This will be clarified under the VIGISUS project. The same is true for periodic newsletters and bulletins which are produced. Few of the data summaries provided critical interpretations of the data. DATASUS produces CD-ROMs of mortality and birth data and makes simplified data sets available on the Internet. The CD-ROMs are distributed to the state health departments. Training is considered a high priority by the FNS (National Health Foundation). A number of excellent programs have been created at the state and federal level to attempt to meet the need for training in disease surveillance and case investigation. These programs have generally been limited in size or duration. In addition, because of high staff turnover, many of the individuals trained have left the public health system. Although one recent training activity developed at the FNS has attempted to harness computer technology, most rely on face-to-face, on-site programs. The AIDS program has attempted to utilize distance-based learning methods. Due to external forces (specifically the telecommunications infrastructure), the public health network has not extensively upgraded communications capacity. Few personnel at the state and municipal level have e- mail access or teleconferencing capability. The Challenge of Decentralization. Decentralization of health activities offers both opportunities and challenges for disease surveillance. It allows redefinition of roles and needs at each level of the surveillance infrastructure, and brings responsibility for decision-making to all the stakeholders. The major challenge is to assure quality and consistency in data collected at the local level. Even within an autonomous, decentralized system, standards must be maintained so that data collected in one jurisdiction can be compared to data collected in another jurisdiction. Otherwise a statewide picture of health status and disease occurrence cannot emerge, nor can a national picture emerge if results are not comparable between states. In such circumstances, this can lead to misidentification of health priorities, and possible maldistribution of health resources to address priority areas. The larger municipalities already appear to function in an autonomously fashion, and have built a high degree of self-reliance. However, the vast majority of smaller municipalities currently have difficulties taking on added responsibilities for surveillance because of resource limitations and inadequate training. Thus, they will need strong support from their state health departments and from regional state offices. Similarly, some state health departments have developed strong capacity, but others will need assistance from their federal counterparts. The roles of the municipal, state, and federal levels have been redefined as follows: (i) the role of the municipal level would be: * primary data collection and reporting of cases; * case interview and investigation; * implementation of public health intervention; * limited data analysis; and * outbreak investigation (ii) the role of the state level would be: * data collation; * provision of technical assistance to municipalities; * primary data collection/investigation for municipalities which cannot perform this function themselves; * data analysis/analytic epidemiological studies; assistance with outbreak investigations, particularly ones that are multi- jurisdictional; * feedback of information to the municipal level; and * reporting of data and of suspected or confirmed outbreaks to the control level (iii) the role of the federal level would be: * data analysis; * provision of technical expertise to states and large municipalities; * support for states with weaker infrastructures to perform their functions; * analytic epidemiological studies; * support for outbreak investigations, especially those that are multistate; systems design/investigation and control guidelines/support; feedback to the state level; and * enhancement of communication with other departments of the MOH that operate disease control programs, at the federal, state, and local levels. There is the need to simplify data needs and collection methods to maximize performance at the municipal level. efforts should be directed in maximizing performance in these areas. Also, efforts must be directed in maximizing performance in the three current national surveillance systems (SINAN, SINASC, and SIM). However, there are many other data needs which are not now being systematically addressed. Under the project, alternative methods could be considered to meet these needs, such as sentinel networks, epidemiological centers of excellence, and periodic surveys. Some examples for alternate surveillance methods would include behavioral risk factor surveys, nosocomial infections, chronic disease burden, and injuries. Public health personnel are strongly motivated to improve their skills in order to do their job as well as possible. They feel that additional resources and training are essentlial to meet their increasingly complex tasks. An important training program has been included in the project to that effect and is presented in Annex 12. There is also a need to enhance the data management telecommunications system. This issue is analyzed in Annex 11. Annex 10 BRAZIL - Disease Surveillance and Control Project (VIGISUS) The System of Public Health Laboratories Introduction. l The Brazilian system of public health laboratories consists of: (i) national reference centers; (ii) macro-regional reference laboratories; (iii) state central laboratories; (iv) biocontainment laboratories; (v) zoonoses centers; entomology centers; (vii) blood banks; and (viii) border laboratories. The network already exits and will be rehabilitated and upgraded under the project. The only exceptions are the border laboratories, and some additional zoonoses centers that will involve new construction. A detailed list of laboratories and their location is available in the project File. National Reference Centers. The network of national reference centers has been defined. These are existing centers of excellence located primarily at major institutes such as the Adolfo Lutz Institute in Sao Paulo, the Evandro Chagas Institute in Belem, the Oswaldo Cruz Institute in Rio de Janeiro, and others. A total of 19 national reference centers has been established and serve to provide technical assistance for specific infectious diseases such as cholera, yellow fever, and measles. The FNS (National Health Foundation) is conducting an evaluation to determine the basic infrastructure and equipment needs of these laboratories, measuring such things as the presence or absence of air conditioning, basic safety devices like eyewash stations, and many other fundamental requirements. The project will help correct the shortfalls identified. Public Health Laboratories. Two categories of public health laboratories are proposed: macro-regional reference laboratories (LRMR), and state central laboratories (LACEN). There are five LRMR, and these are also the major institutions that house the National Reference Centers described above. These are the Evandro Chagas Institute in Belem; the Otavio Magalhaes Institute in Belo Horizonte; the Adolfo Lutz Institute in Sao Paulo; the Central Laboratory of Pemambuco in Recife; and the Institute of Health for the Federal District of Brasilia. Each of these laboratories provides diagnostic and technical assistance not only to the state in which they are located, but also to several adjacent states, typically totaling about five or six states each. There is a total of 27 central laboratories, with at least one located in each state and the Federal District. The central laboratories have already been surveyed by the FNS to identify critical infrastructure and equipment needs. The FNS is conducting an effort to coordinate these laboratories in terms of basic laboratory procedures, laboratory safety, and systematic generation of surveillance data. This annex is based on a report by James W. Leduc of the Centers for Disease Control and Prevention, after a mission to Brazil during February 1-7, 1998 Biocontainment Laboratories. A network of 12 BSL-3 laboratories is being proposed. These will result from renovations of existing BSL-2 facilities. The construction of these laboratories is justified, especially at the major research centers such as FIOCRUZ, the Evandro Chagas Institute, and the Adolfo Lutz Institute. Zoonoses Centers. A large and well-developed network of zoonoses centers has been established by the FNS. These centers focus on four areas: (i) rabies; (ii) leptospirosis; (iii) snake bites; and (iv) human diseases associated with animals such as brucellosis and toxoplasmosis. In addition, they provide other services depending upon the local demands and enzootic diseases. Typical zoonoses centers have professional staff that deal with vector control, insecticide and rodenticide applications, and laboratory analysis of enzootic diseases. They also provide stray dog control and limited analysis of other zoonoses. At present, 93 zoonoses centers are in existence, with an additional 26 in preparation, and about 80 still to be established. Thus, when completed, the zoonoses center network will be comprised of approximately 200 centers. Fundamental requirements for space and personnel has been well defined. In addition, these centers collaborate freely with a network of 32 agricultural laboratories that concentrate on rabies in domestic animals. A CDC visit to the zoonoses center in Brasilia showed that the facility is housed in a large and well-maintained series of buildings first built in 1960. The center's activities focus on rabies prevention, including control of stray dogs, vaccination of animals, and limited diagnosis testing. The facility also provides testing for leptospirosis and visceral leishmaniasis, and is currently involved in a project to examine serums from all the dogs sacrificed during 1998 for evidence of leishmaniasis infection. Should positive-testing dogs be identified, the staff will return to the owners of the dog, or to the area in which the animal was captured if it was a stray, and evaluate the risk of visceral leishmaniasis for the resident population. The laboratory also operates a large vector control operation, including proposed routine assessment of insecticide susceptibility for mosquitoes. They also control domestic rats, and offer services for control of scorpions. The professional staff is composed primarily of veterinarians, but includes a few biologists and entomologists, but no epidemiologists. The program has computer support. In case of human illness with one of the diseases for which the center has responsibility, notification goes from the hospital to the epidemiology coordinator for Brasilia, and from there to the zoonoses center. Center staff then respond as appropriate with on-site investigations and control measures if warranted. Entomology Centers. The entomology centers provide basic investigative services into the biology and distribution of local vector insects, assess and supervise plans of action for vector control, and evaluate vector control operations. Historically, these centers were associated primarily with malaria control activities. They provide local risk assessment of vector-borne diseases, indicate the best methods of vector control, evaluate the impact of control interventions, monitor insecticide susceptibility of local vector species, and conduct limited applied research activities about methods of control and evaluation. At present, there are a total of 47 supervisory medical entomologists or sanitarians, and a staff of over 600 technical assistants. These individuals work in 96 districts within all states (except Amapa and Acre), and 4 locations in the Federal District. Entomology centers are not located within the zoonoses centers, although their functions are closely linked. Under the project, this activity will be merged with the zoonoses centers. They will also be reorganized to better define their responsibilities and utilize their unique services more efficiently. Blood Banks. In Brazil, blood supply is provided both by the private sector (about 30 percent) and the public sector (70 percent). A total of 60 public centers currently exist in Brazil, with at least one in every state and the Federal District. In terms of serving as a source for surveillance information, the centers test all the donated blood for common blood-borne pathogens, including HIV, Chagas diseases, hepatitis B and C, syphilis, and HTLV I/II. Approximately 70 percent of the budget of the centers is spent on serological testing of donated blood. Blood is also tested for hemoglobin content and other hematological conditions, and in many areas information on the clinical conditions of donors is also obtained. Careful analysis of the results of serological testing serves to define research topics, such as determining the reason for extremely high prevalence of hepatitis in the Amazon Region, and could contribute as one source of information for a comprehensive surveillance system. Under the project, the national blood banks will be linked to more efficiently share the relevant information and transfer technology. Border Laboratories. A network of 12 laboratories located along the Brazilian border will be constructed under the project. Brazil has borders with nine countries and there is a significant risk of diseases crossing the border in both directions. These laboratories will have minimal equipment, but will serve to quickly recognize disease threats on both sides of the border, obtain clinical material for laboratory diagnosis, and forward these samples to a reference facility for definitive diagnosis. Financing of Laboratories under the Project. The project will finance: (i) the rehabilitation and equipment of about 105 level-I laboratories; (ii) the construction and equipment of 12 border laboratories; (iii) the transformation of 12 level-II into level-III laboratories through rehabilitation and equipment. The project will finance laboratory and computer equipment. Training of Laboratory Personnel. There is aL critical need for training of laboratory personnel in many areas. This will be addressed under the Project. The most significant is a major need for formal training in epidemiology. To take an example, if one assumes that each zoonoses center should have at least one individual with additional formal training in epidemiology, then approximately 200 trained individuals will be required just for the zoonoses centers. Training is especially important since VIGISUS will decentralize surveillance activities to the state and municipal levels, yet a significant proportion of the epidemiological expertise resides at the federal level, or within the most developed states and major cities such as Sao Paulo and Rio de Janeiro. Training will be undertaken under the form of several regional or state programs rather than a single, centralized effort. This will have the added benefit of training staff on regional problems, and offer a structure whereby students could rotate through the various areas to experience the different endemic disease challenges. Specialized training will also be provided to staff in existing laboratories handling infectious agents and newly-created biosafety laboratories. These individuals will then conduct a series of short courses within the major laboratories on safe laboratory practices and procedures. Finally, there will be a continuing need of ongoing technical training of staff to ensure that they maintain competence in the fast-changing field of biomedical sciences. Each laboratory need not utilize the most sophisticated procedures available, but they should be provided the opportunity for formal and informal information exchange, technology transfer, and effective collaboration. This will be attained through attendance of workshops, congresses, and study tours, to be financed under the project. Details of the training program are provided in Annex 12. Annex 11 BRAZIL - Disease Surveillance and Control Project (VIGISUS) Data Management Telecommunications System The Current System. 'The FNS (National Health Foundation) has developed five major data management systems that are used for public health purposes. All of these systems are in use at each of the Federal, state and municipal levels. They are: (i) live birth certificates and natality reporting (SINASC); (ii) notifiable diseases reporting (SINAN); (iii) death certificates and mortality reporting (SIM); (iv) hospital discharges (SIH-SUS); and (v) ambulatory care data (SIA-SUS) The first three (SINASC, SINAN, and SIM) work similarly to their counterparts in the Centers for Disease Control and Prevention (CDC) in the United States. That is, information is collected on birth certificates, notifiable disease report forms and death certificates, respectively. Those data are then keyed into the various information systems at the municipal or state level and then reported electronically from he municipalities to the state governments and then from the states to the federal government. Other organizations within the FNS have created additional "disease specific" systems, such as those for leprosy, malaria, and tuberculosis (TB). The disease- specific systems differ from the main five listed above in that they are used to follow patients longitudinally rather than to report individual events. Also they collect more detailed data which are very targeted to the individual disease program areas. Even for those health events where longitudinal follow up of patients is not important, other systems of notifiable disease reporting continue to be used within specific disease program areas. These may be paper-based and involve nothing more 'this annex is based on a report by Meade Morgan, Assistant Director for the Science Division of Public Health Surveillance and Informatics, Epidemiology Program Office, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA than the reporting of summary case totals for a given municipality and time period. This has led to the problem where the disease counts from the different systems do not agree. One of the important goals of the new surveillance systems being supported by the VIGISUS project is to eliminate these dual surveillance systems. Currently AIDS is the sole program that relies only on the SINAN system for all case reporting. Data analysis and dissemination are important components of these systems. The SIM, SIH-SUS, SIA-SUS systems currently produce at least yearly public information data sets which are distributed on CD-ROM and are available for real- time interactive analysis on the Internet. The timeliness of the data varies somewhat depending on the system. For example, a public versions of the SIH and SIA data reported through the end of 1997 had already been released in March 1998 while the latest available version of the SIM data is for deaths through 1996. Data from the other two systems, SINASC and SINAN, are released through published reports and statistical summaries. Not only are data from each of the systems made available for analysis, but summary information from various data systems that can be linked at the municipality and higher geographic areas. This allows, for example, infectious disease rates from the mortality system to be compared with those from the notifiable diseases system. Occasionally these systems can also be linked down to the health care provider level. However, they do not currently allow information for individual patients to be linked together. New Systems. In addition to the systems that have been discussed, there are yet other information systems and projects that have either been created or are planned. They include the following: (i) an immunization system (SIPNI) which serves as both an immunization registry and for generating information on vaccine coverage or other statistics useful for program planning and policy development; (ii) a national public health telecommunications network known as the Rede Nacional de Informacoes em Sauide (RNIS)2. The RNIS is being supported under the Bank-financed REFORSUS project. Currently, all state and municipal health agencies located in capital cities have full Internet access -- including e-mail capability. The RNIS project is continuing to expand the information network to even more health department and hopes eventually to provide Internet service to all municipal health departments and public health laboratories. The VIGISUS supported surveillance systems will utilize the RNIS rather than create a separate surveillance telecommunications network. The RNIS plan states that the 2For more infornation on the RNIS system, see http://www.datasus.gov.br/rnis telecommunications network will specifically support the five systems listed earlier: SINASC, SINAN, SIM, SIH-SUS, and SIA-SUS. This is appropriate in that: (i) it reduces duplication of effort; and (ii) using the Internet for data transmission will save VIGISUS considerable development and support costs over the long run; (iii) a new data system (not yet named) summarizing all research data relevant to public health is being planned by the FNS. The data system will be comprehensive and will contain abstracts of information from medical and public health publications, as well as summary data from the public health surveillance systems currently managed by the FNS. It will cover all aspects of public health including the general health status of the population, infectious diseases, chronic diseases, and environmental health at each of the federal, state and municipal levels. The medical research community in Brazil will find this data set especially useful in that it will allow for formal meta-analysis3 of research related to a health condition or disease; (iv) a new public health laboratory information system (also not yet named) is being planned by the FNS. The uses of the system are still being discussed, but at a minimum it will provide for the tracking of individual specimens and the automated collection of laboratory test results; and (v) two environmental health information systems are being planned by the FNS. The first, Sistema de Vigilancia Ambiental (SIVA), will assist primarily in the financial management of control activities. The second, Sistema de Vectores e Reservat6rios (SIVER), will manage information related to the control of vectors and reservoirs for disease transmission. Issues in the Collection and Management of ]Public Health Data. There are a number of issues that relate to the collection and management of public health data. They include: (i) Developing standardized protocols for conducting health assessments of the population at the state and municipal levels. These are undertaken through studies conducted in collaboration between private universities, research institutions, and the FNS. The actual surveys would be conducted by either the states or municipalities through contracts with various universities. The use of a standardized protocol will allow results to be compared across areas and an overall national health assessment to be developed. 3Meta-analysis is a statistical technique that allows information to be combined from a variety of different sources, including raw data such as those produced by the surveillance systems and data from published data summaries. The method allows these different pieces of (possibly conflicting) information to be combined in a meaningful way to investigate issues of interest, including those in public health. (ii) Defining data standards for health information systems. These standards, pertaining to the definition and coding of individual demographic, clinical, and laboratory data elements, will allow the linking of information by health event, by time (for example month and year), and geographic area (for example institution, municipality, and state.) Of particular interest is recent legislation that has been passed at the federal level calling for a new unique patient health services identifier number. If it is indeed implemented, then that number could be used to link individual patient records from multiple sources and collected at different times. It would apply to all health data systems in both the government and private sectors. Currently the FNS is involved in the overall standards setting process. (iii) Redesigning all of the FNS epidemiological surveillance systems so that they will be easier to u-se and will provide more timely, complete and accurate data. New versions of the SINASC and SIM systems, written in Borland Delphi for the 32-bit Microsoft Windows operating systems (Windows '95 and Windows NT) are expected to be released by June 1998. A new version of the SINAN system is being planned for release in January 1, 1999, though mid- summer of that year might be more realistic. In order to meet the deadline, the first version of the system will only be used for a few rather than all 41 diseases. Neither the diseases nor the computer language in which the new SINAN will be developed have yet been deterrnined. (iv) Getting states and municipalities involved. FNS has adopted a formal policy of joint application design (JAD) for all new versions of its data systems, most importantly the new SINAN. Using JAD, the resulting systems are more likely to meet the true needs of the users and all of the stake-holders at all levels of the government (federal, state and municipal). The FNS will include in the process not only representatives from high-capacity areas that have considerable system design and data management expertise, but also those from low-capacity areas that must rely totally on the federal or state governments for providing and supporting their data management solutions. A questionnaire is being developed to ask the states and municipal areas for their ideas and recommendations for the new system. A series of meetings is also planned with as-yet-to-be-selected state and municipal governments to discuss requirements with FNS staff. An important issue being addressed is the need to train states to support the current SINAN while the new system is under development, to involve all levels of government and researchers from disease-specific program areas in the design process, and adopting standards that will apply not only to SINAN but to other data systems within the MOH as well. All disease-specific systems will be eliminated in favor of the new SINAN system. This will be a drastic and important change in the way that the surveillance data system works. With so radical a change in the reporting system being planned, it is very important that experts in each of the disease areas be involved in the design of the surveillance forms and the development of the new SINAN software. This is indeed being planned as part of the JAD process. (v) Connecting additional municipalities to the RNIS network. The REFORSUS- financed RNIS intends to provide Internet access to all State health departments, regional health agencies, and municipal health agencies within three years. This is an ambitious timetable given the lack of infrastructure in some remote areas of Brazil. It amounts to about 6,000 connections, and supporting hardware, software and training (at least) that will need to be provided. To date, only four states (Maranhao, Rio de Janeiro, Sao Paulo, Parana) and the Distrito Federal have had their plans for the RNIS approved -- and these are as pilot projects. Should there be delays in the RNIS implementation, it is perfectly acceptable that diskettes continue to be used to transmit data through SINAN and the various other VIGISUS supported data systems. However, the system would be less efficient. The proposed VIGISUS project will include a provision by which VIGISUS would undertake to finance the implementation of the RNIS should there be undue delays under the REFORSUS project. Financing of the Data Management Telecommunications System. The future telecommunication system is being built on top of the public Internet which should provide the necessary flexibility and capacity to meet both the current and future needs of the system. To complement the support to be provided by the REFORSUS project, under VIGISUS, financing will be provided to: (i) provide micro-computers, printers, telephone links, and vehicles to eligible municipalities; (ii) develop and implement new modules for the public health information system; (iii) provide technical assistance to help the states and municipalities resolve practical issues in implementing the improved and standardized surveillance programs envisioned by VIGISUS; and (iv) improve the data telecommunications system at the central level. Data Management Telecommunications System Implementation Schedule Task Current Status Phase I Objective Phase II Phasn III Objective Objectve Inventory the current health data Maintain the Maintain the Inventory. systems with FNS. inventory. Train States to take over current Training sessions are Dates for "shutdown" of Not applicable. Not applicable. DOS-based SINAN system. underway - to be the current SINAN completed by April system should be set so 30,1998. that users can be prepared to switch to the newer system. At least a one year overlap between the systems is desirable, especially since the new system requires better computers. Develop standard data element The standards setting Continue the standards Continue the Continue the standards setting definitions and coding rules for process as begun and setting process as new standards setting process as new data elements and information throughout the Ministry should be completed data elements and issues process as new issues are identified. of Health, including those supported before the VIGISUS are identified. data elements by the VIGISUS project. project formally and issues are begins. These identified. standards are needed for the new version of the SINAN system which is currently being designed. Develop Internet data security Should be completed by Maintain the Maintain the Interet standards to standards to be applied to all the time the new version Internet standards reflect new and emerging sensifive information transmitted of SINAN is sent into the to reflect new technologies. though the VIGISUS supported field. This would be and emerging systems. sometime in late 1998. technologies. Develop and implement new SIM Prototype expected Maintain and enhance Maintain and Maintain and enhance these and SINASC systems. by late March 1998; these systems, possibly enhance these systems. full implementation providing the option systems. by June 1, 1998 allow providers to directly enter birth and death records via the Internet. Develop and implement new Full implementation A more realistic estimate Maintain and Maintain and enhance the system. notifiable diseases (SINAN) system. expected by for design, development enhance the December 31, 1998. and implementation system. Note: this is overly would be mid-year 1999. optimistic, especially Implement the full system if forms are to be re- with all reportable designed, data diseases in place by definitions and December 30, 1999. coding standards are to be set, and a JAD process is to be used for the system development. However, THE FNS staff feel that this deadline can be met by restricting the I system to a few (not I yet chosen) diseases in the initial software release. Develop and implement new Develop system by Maintain and Maintain and enhance the system. public health laboratory data December 30, 1999; enhance the management system. implement system in 5 system. State reference labs by June 30, 2000. Fully implement the system in all public health laboratories by December 30, 2002. Develop and implement new Develop systems by Maintain and Maintain and enhance the system. environmental surveillance systems December 31, 1999; enhance the (SIVA and SIVER). implement in State health system. departments by March 31, 2000. Create a data base for tracking Design and development Maintain and Maintain and enhance the system. publicly funded health interventions could reasonably be enhance the at the State, local and municipal completed by October 31, system. levels. 1999. However, since this is a new proposal not yet a priority or even agreed to by the FNS, it may take considerably longer if it is done at all. Establish Intemet-based Full Intemet Provide all municipal, Upgrade Intemet Upgrade Intemet connections in at telecommunications network. connections available regional and State health connections to least 500 areas. in all 27 State health agencies with Intemet faster lines in at departments and in access (and the necessary least 1000 areas. municipal health computer hardware and departments for all software) by State capitals. December 30,2002 Conduct surveillance evaluation Develop study protocols Repeat data Continue 5 additional completeness studies for data quality and under- by March 31, 1999. quality study by of reporting studies by December reporting. Conduct data quality June 30, 2002. 31, 2004. study by June 30, 1999. Conduct 10 Implement completeness additional of reporting studies for at completeness of least one health condition reporting studies in 10 States by December in an by 31, 2001. December 31, 2003. VIGISUS Project Implementation Schedule The following table lists specific items that will be checked at the end of Phase-I to help determine if the VIGISUS project is on-track. Item Current Status End of Phase-I Goal Develop and implement data definition Discussions ofstandards arejust beginning. Standards are clearly defined and all and coding standards. THE FNS supported systems use those standards. Develop and fully implement the new Design of the new SINAN system is just beginning. The The old SINAN system is completely SINAN system for notifiable diseases. first version of the system, supporting "a few" diseases, phased out and all notifiable diseases are will be implemented in all States by January 1, 1999. supported by the new SINAN system. Develop and fully implement the public Design of the new public health laboratory data The new system should be in full health laboratory data management management system has not formally begun. It should operation in all public health system. include the ability to electronically transfer patient level laboratories. data into the new SINAN system. Implement the RNIS Intemet network. Currently 5 State-level pilot projects have been fully All municipal, regional, and State health funded. departments have full Internet access. Implement surveillance validation No surveillance evaluation studies have been done. Ongoing studies of the accuracy of studies reported surveillance data are underway. Further, at least 10 State health departments have conducted completeness studies for at least one disease each. Create data system for tracking No system for currently tracking interventions currently This is still under discussion with the interventions exists. FNS. Should agreement be reached by June 1999, the data system should be fully operational by the end of phase 1. Annex 12 BRAZIL - Disease Surveillance and Control Project (VIGISUS) Training Program --Description-- Targeted- ridr cost (US$) , --- - f | ~~~Pernel-- Field Epidemiology Training Doctoral level FNS in 1,500,000 Program (FETP)' This program of trainees. 10 collaboration applied epidemiology training is graduates over with CDC designed to foster the professional the first three development of field-trained years. epidemiologists who are competent in the practical application of epidemiological methods to a wide range of public health problems. The trainees will themselves become trainers later. Basic Principles of Outbreak 200 States 200,000 Investigations. This consists of a 2- participants week course, followed by a 6- from month field project, and a one- municipalities week follow-up course. trained Participants would be public health specialists, masters in epidemiology. Data for Decision-Making Train-the- FNS and CDC 300,000 (DDM). The objective is to train trainer course state and municipal public health in single state workers in the rational collection, with 25 analysis, and use of data. The participants course consists of 3 two-week from several courses with structured projects states. Two between courses. Total time: one rounds: 50 year. people trained Public Health Fellowships. Short- Laboratory Consultancies 750,000 term training (2 weeks to six and other arranged months) in other countries. health workers between FNS Since 1980, the CDC has helped in the establishment of FETPs by ministries of health and universities in over 15 countries, including France, Indonesia, the Philippines, Saudi Arabia, Taiwan (China), and Thailand. The program is considered highly successful. Approximately 95 percent of all FETP graduates have remained in government service as epidemiologists and program managers at local, district, provincial, and national levels. Trainees have conducted investigations encompassing virtually every area of public health including vaccine-preventable diseases, diarrheal diseases, malaria and other vector-borne diseases, human immunodeficiency virus, occupational and environmental health, chronic diseases, cancer, and injury prevention. The program will produce 50 graduates over the course of 7 years. It takes about a year to set up the program, thus raising the apparent unit cost of a graduate for the first APL. chosen by the and CDC MOH. 75 fellowships Laboratory Biosafety Training. "New" States and FNS 1,043,000 Curriculum development by CDC trainers to with FIOCRUZ (Brazil). Target train 600 are 60 state and central FNS staff superior and who will serve as trainers in 300 mid-level subsequent training cycles (3 laboratory courses of 1-2 weeks producing 20 personnel trainers each. Computer Training - Laboratory 100 trainers to States 280,000 Reporting. Instruction in use of be trained new computerized laboratory reporting system. Three courses of 33 trainees each. Management Training. To improve 90 public FNS with 720,000 management skills at the state health and ABRASCO level. Ten one-week per month administrators and states courses over a one-year period. from states Training at 2-3 sites per year. and Curriculum development by municipalities ABRASCO and FNS. Environment Surveillance Courses. (to be completed) Communicable Disease Control. 90 high-level FNS and state 476,000 One course per year for 30 staff trained universities in trainees. Total of 120 days2. the Amazon Region __ __ Training of Community Health 540 agents FNS, PACS 403,000 Agents. Two 7-day courses per trained program, state states, and municipalities Training of Indigenous Health 1000 agents 1,000,000 Agents. trained 2 Over 3-4 periods to avoid taking senior staff away from their operational functions for an extensive time Annex 13 BRAZIL - Disease Surveillance and Control Project (VIGISUS) Project Management and Operational Manual The Project Coordinating Unit The project would be coordinated by the FNS, which would establish a Project Coordinating Unit (PCU), that would be directly linked to the Planning Department of the FNS. The PCU will be the continuation of the present Project Preparation Unit, whose Director and part of its management team are former members of the PCU that was successful in turning around the implementation of the two Bank-financed Amazon Basin Malaria and Northeast Endemic Diseases projects. The PCU would have the following responsibilities: (i) promote the project in states and municipalities; (ii) ensure the project's management, including maintaining project records and preparing regular implementation reports; (iii) ensure, with the collaboration of the states and municipalities, and the Bipartite Commissions (CIB)', the execution of the pre-designed part of the project components (infrastructure, training, etc.); (iv) prepare terms of reference, for the hiring of consultants who will assist in implementing the project components, and supervise their work; (v) coordinate the processing (identification, preparation, appraisal, approval by the CIB, and supervision) of subprojects presented by municipalities and states, ensuring compliance with the Operational Manual; (vi) ensure that states, municipalities, and other executing agencies comply with Bank procurement guidelines; (vi) ensure the provision of technical assistance to weaker states and municipalities for the preparation of subprojects, and for procurement; (vii) undertake the financial management of the project; (viii) operate a management information system to track project processing; (ix) ensure the auditing of project accounts and other audits required by the Bank; (x) coordinate Bank supervision missions, and carry out the mid-term review of the project; and (xi) organize the evaluation of the project's impact using monitoring indicators, analysis, and other appropriate methodology. iBipartite Commissions are commissions, at the state level, with equal representation from the State Secretariats of Health and from the Council of State Municipal Secretariats Project Implementation Each project component will be implemented in two ways: (i) activities that are already pre-designed (e.g. rehabilitation and equipment of state laboratories, epidemiological surveillance training programs, etc.) will be executed according to an implementation schedule by the central FNS, the states, municipalities or NGOs; these activities and schedules are included in an Operational Manual, satisfactory to the Bank; (ii) subprojects that will be presented by municipalities, states, and NGOs, which are not pre- designed, but are prepared by subproject sponsors and evaluated according to eligibility and evaluation criteria included in the Operational Manual. Operational Manual Size and Targeting of Funds. For each component, the Operational Manual allocates funds between pre-designed activities and between subprojects. For pre-designed activities, funds are allocated on the basis of cost estimates. For subprojects, funds are allocated to states (and municipalities) using a transparent allocation formula based upon population and incidence of disease criteria. The detailed allocation tables are part of the Operational Manual. The objective is to reach the financing targets presented in these tables, and technical assistance would be provided to help attain this objective. However, if despite reasonable support from the project management, some states (and municipalities) continue to perform poorly, part of their funds could be reallocated to better performers. This methodology has already been successfully implemented in the Bank-financed Second Northeast Basic Health Services Project and has helped improve the efficiency of implementation of this project while maintaining fairness and equity. Direct Beneficiaries Direct beneficiaries would be health providers at all three levels of government, health sector professionals, and ultimately the whole population as improved surveillance would result in better prevention and control of diseases. Sponsors. Sponsors (or presenters) of subprojects would consist of municipalities, states, other public institutions (e.g. universities, foundations) and NGOs. Cofinancing. On average, subprojects would be financed as follows: 50 percent by the Bank, 35 percent by the FNS; 10 percent by states; and 5 percent by municipalities and others. Subproject Cycle. The subproject cycle and eligibility and appraisal criteria would be included in the Operational Manual. They are summarized below. Promotion. The Coordination Unit (PCU) would invite sponsors to identify subprojects for financing under the project. Representatives from the PCU would visit states and municipalities to transmit and explain subproject eligibility and appraisal criteria. Technical assistance would be provided to weaker municipalities and states in the areas of project preparation and procurement, notably. Preparation. Subprojects would be prepared by sponsors using: (i) the eligibility and appraisal criteria included in the Operational Manual; and (ii) the guidelines for subproject preparation and appraisal. Appraisal and Approval. Subprojects would be appraised and approved as follows: Size;of Subprojects (US$) Appraised by by <350,000 State's Bipartite CIB Commission (CIB) 350,000 - 3,000,000 CIB PCU/FNS > 3,000,000 PCU FNS/Bank Signing of Subproject Agreement. An agreement would be signed between the FNS and the sponsor, delineating the obligations and rights in undertaking subprojects, assigning responsibilities to the respective parties, and specifying criteria for the sustainability of the subproject. Implementation. For each subproject, contracting would be undertaken for civil works, goods, and consultants, using procurement procedures satisfactory to the Bank. Within 30 days of the end of each month, the sponsors would remit a subproject statement of expenditures to the PCU. Supervision would be undertaken by the PCU and the states. Part of the supervision may be contracted out to private consultants. Eligibility Criteria Eligibility criteria are necessary but not sufficient conditions that must be met by the subprojects. These include: (i) a preliminary supply and demand study taking into consideration the population to be covered, its epidemiological profile, and the existing supply of services; (ii) the integration of the proposal within Brazil's disease surveillance and control system; (iii) an implementation plan with start-up and completion dates and phases of implementation. Subprojects that do not fulfill the eligibility criteria would be immediately returned to the sponsor. Those that qualify would be analyzed using the appraisal criteria. Type of Subprojects. Subprojects would include one or more of the following elements: rehabilitation, expansion or construction of facilities, equipment, training and technical assistance, drugs (in some particular cases for subprojects in the Amazon Region) and operating costs (also in particular cases in the Amazon Region and for indigenous health, on a declining basis). Appraisal Criteria The subprojects presented would be appraised using the following criteria. Economic Evaluation. Analysis of supply and demand, taking into consideration: (i) the population's epidemiological profile; (ii) existing capacity within the municipality, the state, or the region, and possible modifications in capacity through changes in operating methods (organization, working hours, etc.); and (iii) coherence with municipal and state health plans. Technical Evaluation. This would include the review of: (i) compliance with MOH and FNS norms and other technical criteria in the Operational Manual; (ii) sponsor's proposal to improve the quality of services; and (iii) architectural plans and engineering drawings, when applicable. Institutional Evaluation. Analysis of availability of specialized staff to operate and maintain the facilities and equipment. Financial Evaluation. The sponsor should have the fiscal and management capability to carry out the subproject as demonstrated in the analysis undertaken as part of subproject preparation. The capacity of a sponsor to implement the subproject would be based on an analysis of the following: (i) availability of counterpart funds to finance the investment cost of the subproject; (ii) availability of funds to finance trained personnel to operate the rehabilitated or new unit and the new equipment; (iii) availability of funds to finance recurrent costs (based on historical budgets and new financing mechanisms under the Unified health System (SUS); and (iv) an operation and maintenance plan. Environmental Evaluation. Analysis of possible negative environmental impact (solid, liquid, and gaseous wastes, or other risks) and of proposed measures to mitigate the negative effects. Impact Evaluation. Each subproject would present a set of indicators (e.g., of efficiency or quality) that would be used to measure the impact of the subproject. Ranking. Subprojects would be ranked using objective criteria and a points system. Higher-ranking subprojects would be approved first. To ensure fairness, technical assistance would be provided to municipalities and states whose proposals consistently rank lower. Mid-Term Review Timing. The VIGISUS mid-term review mission will take place in September 2000. The Bank mission will be composed of Jean-Jacques de St. Antoine (Team Leader), Anabela Abreu (Health Specialist), Christian Hurtado (consultant), as well as specialists in the areas of laboratories, data telecommunications, environmental surveillance, and indigenous populations. Background. The purpose of the mid-termn review is to evaluate project performance during implementation, to provide project management with immediate feedback on project achievements as well as on areas needing improvement, to justify and orient eventual changes in project design, and to document the status of project execution thoroughly for the benefit of the client. The mid-term review procedure consists of an initial period of approximately two weeks when a team designated by VIGISUS collects and reviews information assembled by the project since the beginning of project implementation, focusing on technical, administrative, and financial aspects of the project. Following this fact-finding period, the review team analyzes the information collected, reviews progress against original targets, and prepares a brief report highlighting strengths and weaknesses, and makes recommendations for management action. It would need to cover the whole project period from the beginning of implementation and cover areas described below in the terms of reference. The Bank mission will review that report and undertake field visits to subproject sites at the beginning of the mission. Then it will join the VIGISUS management team to discuss its findings and recommendations, and arrive at concrete agreements regarding targets to be reached and changes to be made in project management and implementation. Objectives. The main objectives of the mid-term review are to: (i) verify compliance with actions previously agreed; (ii) undertake a technical review of subprojects; (iii) undertake an administrative and financial review of VIGISUS; (iv) carry out an impact analysis; (v) assess innovations introduced by the project; (vi) verify progress in research and studies; and (vii) agree on follow-up actions. Specific Aspects to be Reviewed in each Area. The review of compliance of actions previously agreed will consist in checking the progress on actions agreed during last supervision mission. The review of progress in decentralization of the FNS will include an assessment of the extent to which the FNS is being transformed from a federal vertical program organization toward a mostly regulatory agency. The review will also analyze to what extent states and municipalities are assuming the roles expected from them as described in Annex 9. The technical review of project activities will include an assessment of progress in: (i) rehabilitation of laboratories; (ii) rehabilitation of cold chains and other health facilities; (iii) data telecommunications system; (iv) environmental surveillance; (v) training; (vi) studies and research; (vii) disease control in the Amazon; and (viii) indigenous health. The technical review of subprojects will include an assessment of: (i) progress made in the implementation of an integrated disease surveillance model; (ii) the quality of subprojects; (iii) the sustainability of subprojects; (iv) the procedures for processing subprojects from identification to supervision; (v) the efficiency of subproject execution, procurement, and contractual practices; and (vi) the institutional capacity of executing agencies. The administrative and fmancial review will focus on: (i) overall performance of the PCU of VIGISUS and its link to the FNS; (ii) personnel administration, recruitment, and retention of quality staff, (iii) accounting procedures and results of financial audits; (iv) efficiency of management information systems; (v) analysis of overhead costs to determine whether VIGISUS is achieving its objectives in a cost-effective way; (vi) financial projections; (vii) procurement administration; and (viii) disbursement of funds for subprojects. The review of the project's innovative aspects will review innovations introduced by the project in terms of new concepts in disease surveillance and control, or in the processes used to implement subprojects, and will assess the extent to which further innovations can be introduced during the rest of the project life or in VIGISUS II. Detailed terms of reference for the evaluation of the disease surveillance and control system will be presented by the MOH to the Bank. The evaluation of the system at the end of the project will be based on objective factors such as the capacity of the system to monitor each health event taking into consideration sensitivity and specificity, the efficiency, representativeness, timeliness, and flexibility of the system, the feedback provided, the level of training of the personnel, the use of data for decision-making, and the speed of response to outbreaks. Finally, the review will assess VIGISUS performance compared to indicators and will conclude with agreements for actions to be taken by VIGISUS or by the Bank that will help improve the implementation of the project or serve as lessons learned for the implementation of VIGISUS II. Overall Monitoring and Evaluation Study A study will be undertaken during year 3 of the project to assess: (i) compliance with performance indicators; (ii) economic impact of the project and sustainability; and (iii) overall evaluation of the disease surveillance system as a whole. Compliance with monitoring indicators will be assessed by using the indicators presented in Annex lb as well as data presented by the PCU. The analysis of the economic impact of the project and its sustainability will use the framework presented in Annex 6 and data presented by the PCU and collected in the field. Assumptions originally used will be verified through data analysis (e.g. average cost of hospital stay) and field visits. The overall evaluation of the disease surveillance system will use objective factors such as capacity of the system to monitor each health event taking into consideration validity and reliability of data, sensitivity2 and specificity3, the efficiency, representativeness, 2 sensitivity is the proportion of persons with a disease/health event that are detected by the surveillance system timeliness, and flexibility of the system, the feedback provided, the level of training of the personnel, the use of data for decision-making, and the speed of response to outbreaks. It will also evaluate the usefulness and cost of the system. Detailed TORs for the monitoring and evaluation study will be presented by the PCU no later than September 30, 2000. 3 specificity is the proportion of persons without a disease/health event that are detected by the surveillance system Annex 14 BRAZIL - Disease Surveillance and Control Project (VIGISUS) Indigenous Health Development Background. Although VIGIGISUS would benefit the entire Brazilian population, particularly the poor who are affected disproportional by communicable diseases, its main stakeholders are institutions (local and state governments, research institution, universities, laboratories.) However, by adding a specific component to address indigenous peoples health, notoriously the most vulnerable of all groups in Brazil, in addition to the institutional actors, the indigenous are recognized as an identifiable stakeholder/beneficiary of VIGISUS. By conducting preparatory missions in the field, and through other formal consultation processes, the key institutional stakeholders of VIGISUS took an important role in the design of the project. The challenge faced by the social assessment was how to incorporate the views and aspirations of the indigenous groups, traditionally invisible in the Brazilian scenario. To face this challenge, an indigenous health development plan was agreed with the Coordena9co de Sauide Indigena, in FNS (COSAI/FNS). This plan was designed through participatory tools, and discussed in a workshop with representatives of indigenous peoples, indigenous NGOs and community groups, and main civil and governmental institutions concerned with indigenous rights and indigenous health, included FUNAI. The design of the subcomponent on indigenous health consolidates results and recommendations produced during project preparation by a series of diagnosis on indigenous peoples health in Brazil, particularly in the Amazonian region. In addition, it incorporates results from several consultations with indigenous people representatives, indigenous NGOs, universities, and other governmental organizations that participate in indigenous policies and programs in Brazil. COSAI/FNS as the counterpart of the Bank responsible for designing and implementing the subcomponent, was the institution responsible for designing the plan that resulted in the programmed activities of the indigenous health subcomponent. The indigenous health subcomponent should be read as the indigenous health development plan for the proposed project. Among others, the following institutions were consulted and collaborated through their recommendations to the proposed design of the indigenous health subcomponent: Associacao dos Professores e Monitores Indigenas Surud, Associacao Indigena Pankararil, Associa9ao dos Povos Indigenas de Minas Gerais e do Espirito Santo, Protecao Ambiental Cocoalense, Documentacao Indigena e Ambiental, Comissao pela Criacao dos Povos Yanomami, Uniao das Nacoes Indigenas, Federacao das Nacoes Indigenas do Rio Negro, Diocese de Sao Gabriel do Amazonas, Conselho Indigena de Roraima, Agentes Indigenas de Sauide Satere, Conselho de Saiide de Guarapuava, Distrito SanitarioYanomami, Amerindio Coperaci6, Coordenacao das Nac6es Indigenas da Amaz6nia, Representa9&o das Mulheres Indigenas, Conselho Indigenista Missionario, Medecins sans Frontieres, Fundacao Nacional do Indio, Fundacao Oswaldo Cruz, Universidade Federal do Estado de Sao Paulo, Universidade Federal do Amazonas, Associaqqo Brasileira de Antropologia, Secretaria Municipal de Saude, Secretaria Estadual de Sauide do Mato Grosso. Prevalent Diseases. There is not an information system with reliable health indicators for the indigenous population (one is proposed by VIGISUS that will be integrated into the surveillance information system.) According to what is available, the main diseases affecting indigenous peoples are: (a) those provoked by unsafe water: cholera, diarrhea, and hepatitis A; (b) those that are transmissible: tuberculosis, and hepatitis B; (c) acute respiratory infections; and (d) diseases provoked by malnutrition. In the Amazon Region, there is also a high prevalence of malaria, leishmaniosis smallpox, dengue and measles. Suicide is high among some ethnic groups. AIDS and cancer are beginning to be prevalent, and alcoholism is also increasing among many groups. Population. The indigenous population account for less than 0.3 percent of the entire Brazilian population. An estimated 310,000 indigenous people are spread across 24 states (out of 27 states), with about 70 percent of them living in the states comprising the Legal Amazonian ( Acre, Mato Grosso, Amapa, Para, Amazonas, Rondonia, Goias, Roraima, Maranhao, and Tocantins.) VIGISUS will benefit indigenous peoples living in 18 states, targeted by the greatest number of indigenous and by their epidemiological profile. Indigenous living in 257 municipalities will be covered by the project. The states of Alagoas, Espirito Santo, Goias, Sao Paulo and Rio de Janeiro, whose indigenous population totals less than 10,000, will continue to be covered through other regular programs of FNS. Institutional Responsibilities. The responsibilities for the health status of indigenous peoples health are split between Ministry of Health/FNS/COSAI and FUNAI. The former holds the responsibilities for prevention, whereas FUNAI holds responsibilities for primary and secondary health care. Currently, a new law is being discussed in Congress that attributes integral attention to indigenous health to the Ministry of Health, relating this care to some of the SUS decentralized mechanisms of health care provision. The VIGISUS project will help prepare FNS to assume its upcoming legal responsibilities. At the same time VIGISUS supports activities presently being undertaken by both the Ministry of Health/FNS/COSAI and FUNAI. Therefore, until the new Law is approved, FUNAI should be considered as a beneficiary of the project that will be in charge of some of the key proposed investments, including training for indigenous health agents. Although health care for indigenous groups is considered a federal responsibility, according to the Norma Operacional Basica do Sistema Unico de Sauide (NOB/SUS/96), this should be shared with states and municipalities. Financial transfers from SUS to municipalities are based on the number of residents in each of them. Thus, transfers take into account the number of indigenous residents. However, the fact that the latter live in the most remote areas make health services provided by SUS through municipal governments almost inaccessible to them. Both FUNAI and COSAI/FNS have a weak capacity to respond efficiently to the demand of providing decent health care and access to reliable health services to the indigenous population. The project will face this challenge by: (a) strengthening and training the staff of institutions involved in indigenous health, at the federal, state, and municipal levels, including universities, research centers and NGOs; (b) supporting an information on indigenous health that will allow a rational plan of investments and monitoring of results; (c) training of indigenous health agents and training of new ones; (d) building and rehabilitating safe water system in indigenous localities; (e) building and rehabilitating health posts in indigenous localities; (f) building and rehabilitating Casas do Indiol, in state capitals; (g) supporting the creation of indigenous sanitary districts (distritos sanitarios indigenas); and (h) supporting and empowering indigenous groups organizations to participate of VIGISUS. All these activities were recommended by two National Health Conferences and by one National Indigenous Health Conference and by the consultation activities undertaken during preparation. Non-traditional health services: health posts and indigenous health agents. Living far away from municipal centers where health services are available, health posts are frequently the only place where indigenous individuals can get access to health care. Most often, this care is provided by the indigenous health agents, whose training is FUNAI's responsibility. The surveillance system supported by VIGISUS would also rely on those agents for notification of communicable diseases. FUINAI also holds the responsibility for building and maintaining these posts. Nonetheless, not adequately funded, FUNAI has been unable to maintain them as well as to train new and retrain the existent indigenous health agents. Increasingly this responsibility has been informally taken over by FNS/COSAI, working collaboratively with FUNAI at the local level. As recommended by the workshop, both the infrastructure and training activities would be supported by the project. I Facilities designed to receive indigenous patients and relatives before referring them to the nearest health service available, and host convalescent patients before they return home. Annex 15 BRAZIL - Disease Surveillance and Control Project (VIGISUS) Project Processing Budget and Schedule A. Project Budget(US$) Planned Actual (At PCD Stage) 200,000 204,000 B. Project Schedule Planned Actual (At PCD Stage) Time taken to prepare the 12 months 10 months project (months) First Bank mission September 1997 September 1997 (identification) Appraisal mission departure May 1998 April 1998 Negotiations June 1998 July 1998 Planned date of January 1999 effectiveness Prepared by: Brazil's National Health Foundation Preparation assistance: Bank, CDC, WHO, and PAHO Bank staff and consultants who worked on the project include: Jean-Jacques de St. Antoine (Task Manager), Anabela Abreu, Roque Ardon, Girindre Beeharry, Orville Grimes, Renato Gusmao, Robert. Hahn, Douglas Hamilton, Christian Hurtado, Juan David Quintero, James Le Duc, Jay Mc Auliffe, Bernard Montaville, Sarah Menezes, Alberto Ninio, Thomas Novotny, Valeria Junho Pena, Carol Pertowsky, Francisco Pinheiro, Richard Skolnik, Morag van Praag, and Diana Weil. Annex 16 BRAZIL - Disease Surveillance andl Control Project (VIGISUS) Documents in the Project File Projeto VIGISUS - "Missao de Preparacao e Negociacao (9tO3/98-13/03/98)". Procurement Arrangements, Memo to Files, June 4, 1998 Guia para o Manejo Interno de Residuos Solidos em Estabelecimentos de Sau~de. Health Surveillance and Public Health Laboratories in Brazil - the Final Report of 2 CDC Missions. Leduc James W., Communicable Diseases Project (VIGISUS) 1-7 February, 1998. "Estudo de Impacto na Area de Vigila.ncia Ambiental", Fundacaio Nacional da Sauide. "A^nalise de Capacidade Institucional de Estados e Municipios para assumirem o V\IGISUS", Fundacao Nacional da Sauide. "Regimento Interno", Fundacao Nacional da Saude. "0 Ministerio da Sauide em Movimento de Transformacao", Fundacao Nacional da Saude. "Estrutura Regimental (Decreto No. 2477, de 28.01.98)", Ministerio da Sauide. "Field Epidemiology Training Programs (FETP)", CDC, October 1994. "NOB - SUS 01/96", Brasilia 1997. "NOB No. 1/96" Recife Setembro 1997. "Mensagem ao Congresso Nacional", Presidente Fernando Henrique Cardoso, 1998. "Tuberculosis Program Review", World Health Organization, Brazil, July 1994. "Fact Book FY 1995", Centers for Disease Control and Prevention . "Staff Appraisal Report - Brazil - Northeast Endemic Disease Control Project (Report 6837-BR)", World Bank, January 19, 1988. "Staff Appraisal Report - Brazil - Amazon Basin Malaria Control Project, (Report 7535- BR)", World Bank, April 21, 1989. "Implementation Completion Report - Brazil - Northeast Endemic Disease Control Project (Report No. 16694)", World Bank, June 6, 1997. "Implementation Completion Report - Brazil - Amazon Basin Malaria Control Project (Report No. 16482)", World Bank, April 10, 1997. Marier R., "The Reporting of Communicable Diseases", American Journal of Epidemiology, Vol. 105, 1977. Thacker Stephen B., Redmond S., Rothenberg R., Spitz S., Choi K., and White M., "A Controlled Trial of Disease Surveillance Strategies", American Journal of Preventive Medicine, volume 2, number 6, 1986. Teutsch S., Thacker S., "Planificaci6n de un sistema de vigilancia en la salud", Organizaci6n Panamericana de la Salud, Boletin Epidemiol6gico, Vol. 16, No. 1, marzo 1995. Thacker S., Gibson Parrish R., Trowbridge F., & Surveillance Coordination Group, "A method for evaluating systems of epidemiological surveillance", World Health Statistics Quarterly, 1988. Fleming D.M., Cohen J.M., "Experience of European collaboration in influenza surveillance in the winter of 1993-1994", Journal of Public Health Medicine, Vol. 18 NO. 2, 1996. Graitcer P.L., Burton A.H., "The Epidemiologic Surveillance Project: Computer-Based System for Disease Surveillance", American Journal of Preventive Medicine, volume 3, number 3, 1987. Thacker S.B., Choi K., Brachman, P.S., "The surveillance of Infectious Diseases", JAMA, Vol. 249 No. 9, March 4, 1983. "WHO Recommended Surveillance Standards", World Health Organization, October 1997. "Protocol for the Evaluation of Epidemiological Surveillance Systems", World Health Organization, 1997. Annex 17 CS:'° 1. 074 G.M/MS Brudlis(DF), July 30, 1998. Mr. Go" T. Na laI Suhseginml of the Wold Bik SCN Q2 Bloco A, Conj. 303/304 -Ed. Corporate Financial Center 13OliaWDF Dwr Mr. Nankani: Tho Government of Brazil has roquested the World Bank's financial suppont for the Disease Surveillance and Control (ViGISUS) program which is expected to bc implcmented over a period of about 8 ycars. The objective of tho progm is to improvo and strengthen razil's national disease surveillance and control mystem (NSS) to contribute to reduce mortality and morbidity reulting from communicable diseases.'The program will consist in three projects phased over seven yoars that will seek to strengthen the surveillance system nationally through: (i) the improvement of the data management telecommunications system; (ii) the rehabilitation of the laboratory inetwork; Nd (iii) the training of staff. In addition, tho progam would support disease prevention and control in the Amazon Region and for indigenous populations. The pro&= will bc imnplemented in thrce phases, the first of which will take plae from 1999 to 2002. To monitor the implementati6n of the first phase, we have agreed that the following indicators would be used to moasure progress towards the establishment of a viable and efficient national surveillance (i) at least 50 candiddes would have been trained under the "Basic Priciples of Outbreak Invstiption" coure; (hi) at Iat 200 superior-level and 100 mid-level staff would have been tmined in laboratory biomfety; (in) 9 natiosl refortec laboratories would have been rehabilitated uad equipped; (iv) don qad coding standards for the NSS would have been properly defined; (v) th new notifiable diseases reporting system (SINAN) would be flly opertonal in at los 20 national or macroregional public health laboratoies (i.e. that thesc laboratoies have each establishod a systemn to monitor the timeliness of reporting and compliance with tarSets set by the ENS for the key notifiable (vi) 300 indigpnous community health agents would have boen tained; sa (vfi) the number of cases of tuberculosis cured in the Amazon Region would have increaed by at los 10 percent. The Govemment of Brazil, through this Ministry, clarifies and understands tha the accoptanmc of support for this phaus of the VIGISUS program does not nocessarily represent a commitment from the Government nor from the Bank to contract additional loans towards the aforementioned progam. Yours shiccrcly, Ministcr of Hoth, a. i. Annex 18 Statement of Loans and Credits IBRD Loans and IDA Credits in the Operations Portfolio Difference Between expected Original Amount in US$ Millions and actual Loan or Fiscal disbursements a/ Project ID Credit Year Borrower -Purpose No. __ IBRD IDA Cancellations Undisbursed Orne Frm Rev'd Number of Closed Loans/credits: 206 Active Loans BR-PE-35728 IBRD42320 1998 STATE OF BANIA BANIA WTR RESOURCES 51.00 0.00 0.00 51.00 0.00 0.00 BR-PE-38895 IBRD43100 1998 GOVERNMENT OF BRAZIL FED.WTR MGT 198.00 0.00 0.00 198.00 0.00 0.00 BR-PE-38947 IBRD42660 1998 GOVERNMENT OF BRAZIL SC. & TECH 3 155.00 0.00 0.00 155.00 5.00 0.00 BR-PE-39197 IBRD42110 1998 STATE OF RIO DE JANEIRO RJ ST.PRIV. 250.00 0.00 0.00 125.00 50.00 0.00 BR-PE-40033 IBRD43180 1998 THE STATE OF MINAS GERAIS MG STATE PRIV. 170.00 0.00 0.00 170.00 0.00 0.00 BR-PE-42565 IBRD42510 1998 STATE OF PARAIBA PARAIBA R.POVERTY 60.00 0.00 0.00 60.00 0.00 0.00 BR-PE-43420 IBRD42920 1998 FED. REPUBLIC OF BRAZIL WATER S.MOD.2 150.00 0.00 0.00 150.00 0.00 0.00 BR-PE-43421 IBRD42910 1998 STATE OF RIO DE JANEIRO RJ M.TRANSIT PRJ. 186.00 0.00 0.00 186.00 10.00 0.00 BR-PE-48357 IBRD42450 1998 REPUBLIC OF BRAZIL CEN.BANK TAL 20.00 0.00 0.00 20.00 .50 0.00 BR-PE-50162 IBR043110 199e GOV. OF BRAZIL FUNDESCOLAl 62.50 0.00 0.00 62.50 0.00 0.00 BR-PE-51701 . IBRD42S20 1998 STATE OF MARANHAO MARANHAO R.POVERTY 80.00 0.00 0.00 80.00 0.00 0.00 BR-PE-6474 IBRD42380 1998 STATE OF SAO PAULO LAND MGT 3(SP) 55.00 0.00 0.00 55.00 .67 0.00 BR-PE-6549 IBRD42650 1998 TOG GAS SCTR DEV PROJECT 130.00 0.00 0.00 130.00 0.00 0.00 8R-PE-6559 IBRD43120 1998 THE STATE OF SAO PAULO (BF-R)SP.TSP 45.00 0.00 0.00 45.00 2.67 0.00 BR-PE-34578 IBRD41650 1997 RIO GRANDE DO SUL RGS HWY MGT 70.00 0.00 0.00 70.00 7.34 0.00 BR-PE-38896 IBRD41200 1997 STATE OF RGN R.POVERTY(RGN) 24.00 0.00 0.00 21.24 4.14 0.00 BR-PE-39196 IBRD41390 1997 STATE OF RIO GRANDE DO SU RGS ST.REFORH 125.00 0.00 0.00 50.02 20.02 0.00 8R-PE-42566 IBRD41220 1997 STATE OF PERNAMBUCO R.POVERTY(PE) 39.00 0.00 0.00 28.99 3.44 0.00 BR-PE-43868 IBRD41480 1997 STATE OF RGS RGS LAND MGT/POVERTY 100.00 0.00 0.00 97.00 11.10 0.00 BR-PE-43871 IBRD41210 1997 STATE OF PIAUI (PIAUI)R.POVERTY 30.00 0.00 0.00 24.98 4.28 0.00 BR-PE-43873 IBRD41690 1997 FED.REP.OF BRAZIL AG TECH DEV. 60.00 0.00 0.00 55.51 8.83 0.00 BR-PE-46052 IBRD41900 1997 CEARA WTR PILOT 9.60 0.00 0.00 8.92 -.68 0.00 BR-PE-48870 IBRD41890 1997 THE STATE OF MATO GROSSO MT STATE PRIV. 45.00 0.00 0.00 45.00 16.68 0.00 BR-PE-6475 IBRD41470 1997 FED. REP. OF BRAZIL LAND RFM PILOT 90.00 0.00 0.00 75.05 .89 0.00 BR-PE-6532 IBRD41880 1997 FEDERAL GOVERNMENT FED HWY DECENTR 300.00 0.00 0.00 285.00 11.67 0.00 BR-PE-6562 IBRD41400 1997 STATE OF BAIIA BAHIA MUN.DV 100.00 0.00 0.00 98.98 8.65 0.00 BR-PE-37828 IBRD40600 1996 STATE OF PARANA (PR)R.POVERTY 175.00 0.00 0.00 158.64 66.07 0.00 BR-PE-40028 IBRD4046A 1996 FEDERATIVE REPUBLIC OF BR RAILWAYS RESTRUCTURG 151.48 0.00 0.00 142.62 25.95 0.00 BR-PE-6512 IBRD39240 1996 CVRD ENV/CONS(CVRD) 50.00 0.00 0.00 30.13 7.56 0.00 BR-PE-6547 IBRD3633A 1996 FED.REP.OF BRAZIL METRO TRANSP. RIO 47.48 0.00 0.00 27.02 27.32 0.00 BR-PE-6554 IBRD40470 1996 FED. REP. OF BRAZIL HLTH SCTR REFORM 300.00 0.00 0.00 261.09 88.58 0.00 BR-PE-35717 IBRD39170 1995 GOVT OF BRAZIL RURAL POV. (BANIA) 105.00 0.00 0.00 61.37 9.39 0.00 BR-PE-38882 IBRD3915A 1995 FED REPUBLIC OF BRAZIL RECIFE M.TSP 98.72 0.00 0.00 98.72 49.05 0.00 BR-PE-38884 IBRD39180 1995 GOVT OF BRAZIL RURAL POV.- CEARA 70.00 0.00 0.00 46.81 9.15 0.00 BR-PE-38885 IBRD39190 1995 GOVT OF BRAZIL RURAL POV.-SERGIPE 36.00 0.00 0.00 20.21 2.00 0.00 BR-PE-6436 IBRD37890 1995 STATE OF CEARA ZIL CEARA UR.DV/WATER CO 140.00 0.00 0.00 103.61 70.27 -5.40 BR-PE-6564 IBRD3916A 1995 FED REPUBLIC/BRAZIL BELO H M.TSP 83.32 0.00 0.00 78.65 44.36 0.00 BR-PE-6564 IBRD39160 1995 FED REPUBLIC/BRAZIL BELO H M.TSP 15.68 0.00 0.00 .36 44.36 0.00 BR-PE-6452 IBRD36630 1994 MINISTRY OF EDUCATION NE BASIC EDUC III 206.60 0.00 0.00 80.52 60.88 0.00 BR-PE-6522 IBRD37670 1994 ST.OF ESPIRITO SANTO ESP.SANTO WATER 154.00 0.00 0.00 86.36 62.22 0.00 BR-PE-6524 IBRD36390 1994 ST.OF MINAS GERAIS MINAS MNC.DEVELOPMT 150.00 0.00 5.00 34.82 33.13 -2-53 BR-PE-6543 IBRD37330 1994 GOVERNMENT M. GERAIS BASIC EDUC 150.00 0.00 0.00 50.41 17.74 0.00 BR-PE-6546 lBRD36S90 1994 GOVERNMENT AIDS CONTROL 160.00 0.00 0.00 5.89 -.03 0.00 BR-PE-6555 IBRD37130 1994 STATE GOVTS STE HWY MGT II 54.00 0.00 18.00 16.30 12.49 -10.00 BR-PE-6555 IBRD37150 1994 STATE GOVTS STE HWY MGT II 79.00 0.00 18.00 7.52 12.49 -10.00 BR-PE-6558 IORD37660 1994 REPUBLIC OF BRAZIL PARANA BASIC EDUC 96.00 0.00 0.00 29.01 1.83 0.00 Difference Between expected Origioal Amount in USS Millions and actual Loan or Fiscal disbursements a/ Project ID Credit Year Borrower Purpose No. IBRD IDA Cancellations Undisbursed Orig Frm Rev'd BR-PE-6378 IBRD35470 1993 STATE GOVERNMENTS STATE HWY MGMT 50.00 0.00 0.00 3.73 24.02 -2.45 BR-PE-6378 IBRD35480 1993 STATE GOVERNMENTS STATE HWY MGMT 38.00 0.00 18.00 3.63 24.02 -2.45 BR-PE-6427 IBRD36040 1993 MIN. OF EDUCATION -N NE BASIC EDUC II 212.00 0.00 0.00 53.91 40.58 0.00 BR-PE-6540 IBRD35540 1993 MINAS GERAIS ST. WTR Q/PLN(MINAS GERA 145.00 0.00 5.00 20.28 25.27 -7.93 BR-PE-6541 IBRD35030 1993 S.PAULO/PARANA STS. WTR Q/PLN(SP/PARANA) 9.00 0.00 0.00 5.26 77.25 0.00 BR-PE-6541 IBRD35040 1993 S.PAULO/PARANA STS. WTR Q/PLN(SP/PARANA) 119.00 0.00 0.00 34.02 77.25 0.00 BR-PE-6541 IBRD35050 1993 S.PAULO/PARANA STS. WTR Q/PLN(SP/PARANA) 117.00 0.00 8.00 29.99 77.25 0.00 BR-PE-6547 IBRD36330 1993 FED.REP.OF BRAZIL METRO TRANSP. RIO 81.02 0.00 0.00 .29 27.32 0.00 BR-PE-6368 IBRD3442A 1992 GOVERNMENT WATER SECTOR MODERNI 69.62 0.00 0.00 43.23 43.68 0.00 BR-PE-6368 IBRD34425 1992 GOVERNMENT WATER SECTOR MODERNI 167.88 0.00 0.00 .46 43.68 0.00 BR-PE-6454 IBRD34440 1992 GOB RONDONIA NTRL RES. M 167.00 0.00 0.00 37.01 37.00 0.00 BR-PE-6505 IBRD34920 1992 GOVERNMENT OF BRAZIL MATO GROSSO NAT RES 205.00 0.00 0.00 82.02 82.02 0.00 BR-PE-6364 IBRD33750 1991 STATE OF SAO PAULO INNOV BASIC ED 245.00 0.00 0.00 26.63 26.63 0.00 BR-PE-6492 IBRD33760 1991 PETROBRAS BRAZI HYDROCARBN TRNSP/PRO 260.00 0.00 0.00 3.22 3.22 0.00 BR-PE-6446 IBRD31730 1990 FEDERATIVE REPUBLIC OF BR NAT ENVIRONMT 117.00 0.00 0.00 23.53 23.55 0.00 BR-PE-6453 IBRD31700 1990 FEDERATIVE REPUBLIC OF BR NE IRRIG I 210.00 0.00 69.00 28.67 97.69 28.69 BR-PE-6473 IBRD31600 1990 STATE OF SANTA CATARINA LND MQGT II-S. CATAR 33.00 0.00 0.00 .4.05 4.04 -1.94 BR-PE-6370 IBRD30130 1989 FEDERATIVE REPUBLIC OF BR NE IRRI JAIBA 71.00 0.00 0.00 3.91 3.92 0.00 BR-PE-6414 IBRD30430 1989 COMGAS, SAO PAULO NTRL GAS DIST 94.00 0.00 0.00 2.66 2.64 0.00 Total 7,337.90 0.00 141.00 4,094.75 1,551.04 -14.01 Active Loans Closed Loans Total Total Disbursed (IBRD and IDA): 3,116.95 15,767.01 18,883.96 of which has been repaid: 291.92 12,535.05 12,826.97 Total now held by IBRD and IDA: 6,945.87 3,236,01 10,181.88. Amount sold : 0.00 45.83 45.83 Of which repaid : 0.00 45.83 45.83 Total Undisbursed : 4,094.75 4.05 4,098.80 a. Intended disbursements to date minus actual disbursements to date as projected at appraisal. b. Rating of 1-4: see 00 13.05. Annex D2. Preparatlon of Implementation Summary IForm 590). Following the FY94 Annual Review of Portfolio performance (ARPP), a letter based system will be used (NS - highly Satisfactory, S - satisfactory, U - unsatisfactory, HU - highly unsatisfactory): see proposed Improvements in Project and Portfolio Performance Rating Methodology (SecM94-901), August 23, 1994. Note: Disbursement data is updated at the end of the first week of the month. Brazfil STATEMENT OF IFC's Committed and Disbursed Portfolio As of 30-Apr-98 (In US Dollar Millions) Committed Disbursed IFC IFC FY Approval Company Loan Equit Quasi Partic Loan Equit Quasi Partic y y 1973/78/83 CODEMIN 0.00 4.34 0.00 0.00 0.00 4.34 0.00 0.00 1975/96 Oxiteno NE 30.00 0.00 0.00 0.00 30.00 0.00 0.00 0.00 1980/87/97 Ipiranga 40.00 6.32 0.00 150.0 0.00 6.32 0.00 0.00 0 1980/88 OPP 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1980/92 DENPASA .15 1.00 .12 0.00 .15 1.03 .05 0.00 1981 Brasilpar 0.00 .04 0.00 0.00 0.00 .04 0.00 0.00 1982/84/86 PISA 0.00 3.90 0.00 0.00 0.00 3.90 0.00 0.00 1982/86 Cimento Caue 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1983 SOCOCO 0.00 0.00 2.50 0.00 - 0.00 0.00 2.50 0.00 1984 ALQUIM 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1987/92/96 MBR 10.78 0.00 10.00 11.97 10.78 0.00 10.00 11.97 1987/96 Perdigao 32.81 10.00 0.00 18.00 32.81 10.00 0.00 18.00 1987/96/97 Duratex 22.00 0.00 0.00 78.00 22.00 0.00 0.00 78.00 1987/97 SP Alpargatas 25.00 0.00 5.00 0.00 20.70 0.00 5.00 0.00 1989 ELUMA 0.00 0.00 3.00 0.00 0.00 0.00 3.00 0.00 1989 Politeno Linear 1.70 0.00 0.00 0.00 1.70 0.00 0.00 0.00 1990 ENGEPOL 1.31 0.00 0.00 0.00 1.31 0.00 0.00 0.00 1990 Ripasa 5.71 5.00 0.00 0.00 5.71 5.00 0.00 0.00 1990/91/92 Bahia Sul 16.43 20.97 0.00 5.00 16.43 20.97 0.00 5.00 1991 Bradesco-AL 26.03 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1991 Bradesco-Bahia 5.25 0.00 0.00 0.00 5.25 0.00 0.00 0.00 1991 Bradesco- 7.50 0.00 0.00 0.00 7.50 0.00 0.00 0.00 Eucatex 1991 Bradesco-Petrofl 7.50 0.00 0.00 0.00 7.50 0.00 0.00 0.00 1991 Bradesco-Romi 2.38 .40 0.00 0.00 2.38 .40 0.00 0.00 1991 Rhodia-Ster 8.57 5.95 0.00 0.00 8.57 5.95 0.00 0.00 1992 CRP-Caderi 0.00 2.00 0.00 0.00 0.00 .75 0.00 0.00 1992/93 TRIKEM 0.00 12.86 0.00 0.00 0.00 12.86 0.00 0.00 1993 BACELL 12.50 10.70 0.00 25.20 12.50 10.70 0.00 25.20 1993 Coteminas 0.00 4.00 0.00 0.00 0.00 4.00 0.00 0.00 1993 CEBRACTEX 1.80 0.00 0.00 0.00 1.80 0.00 0.00 0.00 1993 Macedo 16.08 0.00 0.00 0.00 16.08 0.00 0.00 0.00 Alimentos 1993 Votorantim 14.29 0.00 0.00 1.14 14.29 0.00 0.00 1.14 1993/96 CEVAL 53.86 20.00 0.00 118.1 53.86 20.00 0.00 118.14 4 1994 GAVEA 10.00 0.00 5.50 0.00 10.00 0.00 5.50 0.00 1994 GP Capital 0.00 16.36 0.00 0.00 0.00 16.32 0.00 0.00 1994 Para Pigmentos 30.00 9.00 0.00 35.00 25.50 9.00 0.00 29.75 1994 Portobello 15.79 5.00 0.00 0.00 15.79 5.00 0.00 0.00 Committed Disbursed IFC IFC FY Approval Company Loan Equit Quasi Partic Loan Equit Quasi Partic y y 1994/95/97 Sadia 50.00 10.00 10.00 200.8 50.00 10.00 10.00 200.88 8 1994/96 CHAPECO 25.00 0.00 0.00 5.00 25.00 0.00 0.00 5.00 1994/96 S.A.I.C.C. 0.00 7.85 6.87 0.00 0.00 7.70 6.87 0.00 1995 Bradesco-Hering 7.50 0.00 0.00 0.00 7.50 0.00 0.00 0.00 1995 Brahma - BRA 32.50 0.00 0.00 86.10 32.50 0.00 0.00 86.10 1995 Cambuhy/MC 22.50 0.00 0.00 0.00 22.50 0.00 0.00 0.00 1995 Lojas Americana 28.00 0.00 5.00 18.00 28.00 0.00 5.00 18.00 1995 LATASA- 15.67 0.00 0.00 3.00 15.67 0.00 0.00 3.00 Brazil 1995 Politeno Ind. 17.54 0.00 0.00 0.00 17.54 0.00 0.00 0.00 1995 Rhodiaco/PTA 25.00 0.00 0.00 24.00 25.00 0.00 0.00 24.00 1995/96/98 Globocabo 35.00 27.97 0.00 118.0 35.00 27.97 0.00 118.00 0 1996 Banco Bradesco 40.00 0.00 0.00 60.00 0.00 0.00 0.00 0.00 1996 Banco Liberal 10.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1996 Mallory 8.00 3.96 0.00 0.00 8.00 3.96 0.00 0.00 1996 TIGRE 25.00 0.00 5.00 21.36 25.00 0.00 5.00 21.36 1996/97 Lightel 25.00 18.17 0.00 0.00 25.00 18.17 0.00 0.00 1997 Bompreco 25.00 0.00 5.00 0.00 0.00 0.00 0.00 0.00 1997 Copesul 40.00 0.00 0.00 180.0 32.00 0.00 0.00 144.00 0 1997 Rodovia 35.00 0.00 0.00 79.50 16.81 0.00 0.00 37.83 1997 Samarco 18.00 0.00 0.00 16.00 18.00 0.00 0.00 16.00 1997 Sucorrico 15.00 0.00 0.00 0.00 15.00 0.00 0.00 0.00 1997 Wembley 0.00 10.00 0.00 0.00 0.00 10.00 0.00 0.00 1997 Wentex 15.00 0.00 0.00 20.00 15.00 0.00 0.00 20.00 1998 BSC 14.00 0.00 0.00 7.50 14.00 0.00 0.00 7.50 1998 Empesca 25.00 0.00 10.00 0.00 5.00 0.00 10.00 0.00 1998 Saraiva 15.00 3.00 0.00 0.00 15.00 3.00 0.00 0.00 Total Portfolio: 966.1 218.7 67.99 1,281. 770.1 217.3 62.92 988.87 5 9 79 3 8 Approvals Pending Commitment Loan Eguit Quasi Partic 1996 AGUAS 17.00 100 0.00 23.00 LIMEIRA 1998 ARTEB 20.00 7.00 0.00 20.00 1998 BANCO ICATU 30.00 0.00 0.00 0.00 1997 COPESUL 0.00 0.00 0.00 45.00 BLINC. 1997 CTBC 35.00 0.00 0.00 150.0 0 1996 GLOBOCABO 0.00 0.00 0.00 38.00 II 1997 GUILMAN- 30.00 0.00 0.00 90.00 Committed Disbursed IFC IFC FY Approval Company Loan Equit Quasi Partic Loan Equit Quasi Partic y y AMORIM 1998 ICATU EQUlITY 0.00 30.00 0.00 0.00 1997 IPIRANGA 0.00 0.00 5.00 0.00 EXPANS. 1997 IPIRANGA RI 0.00 .32 0.00 0.00 1998 LOJAS 16.00 4.00 0.00 0.00 RENNER 1997 NOVA DUTRA 0.00 0.00 0.00 10.00 BLINC 1996 OXITENO/ETH 0.00 5.00 0.00 0.00 YLO 1998 SANTHER 25.00 0.00 10.00 45.00 1997 SP 0.00 0.00 0.00 30.00 ALPARGATAS 1998 TRIKEM II 25.00 0.00 0.00 0.00 1998 UNIBANCO 40.00 0.00 0.00 250.0 0 1997 UNIBANCO 50.00 0.00 0.00 0.00 LIVESTO 1998 VARGA 20.00 0.00 3.00 15.00 Total Pending 308.0 47.32 18.00 716.0 Commitment: 0 0 Annex 19 Brazil at a glance , Lain Uppe POVERTY N SOCIAL Amolde razil & Ct Ineomn Development diamod Popon mid-1996 (muons) 1612 485 479 GNP per apIt 19 (O.1S8) 4.380 3,710 4.540 1. GNP 1906 (9 1$) 70.9 1.799 2,173 Ave annual rowth, 139646 Popa N (If) IA 1.7 1.5 G G Labofra) 1.5 2.3 1.8 GNP Gross Mostuuoentesnate (b ytevra 1b9Ml9) aenml\et Poverty: hbeednt he (W Of,Wd*DnJ 17 UMan popodtn (% IOf11lpoPe111n) 78 74 73 nl *mlexpecksicy at ,OOD & ) 67 60 69 Cbat m I tafty ue 1,00 he ..) 3. to so _ CI'JdmWrA*bn (%fof divwumdr 4 Is ces b s wakr % dpepullon 92 30 66 1Uls ra dopopiSbnp el.) 17 13 13 Grmss ptrln enimnen "W d ofl.ege pape*bon) 114 110 107 F_- -. ..pNud.~cm .. Femmle __________________ KEY ECONOMC RATIOS ad LONG-TERN TRENDS 1376 1#5 ION 13 EconkomIc ratios GDP (bns USt) 121.0 22Z9 716.9 74.7 G3nSS dome_H. invehOinenWDP 26.8 19.2 20.1 19.5 Esof of goods and swviceWGoP 7.5 12.2 6.7 66 Opnns of Groes doesc savlWgaIDP 22.9 24.4 19.2 16.2 Gres natonal sNgelGtP 21.1 19.3 17.6 16.3 Current ac.unt blanoeGDP .6.6 .02 -2.5 -3.2 Intet peymWetlGOP 1.7 3.3 1.2 1.7 Sa^s 7g Investment Tol debJGDP 22.4 46.6 22.2 23.5 Totl debt evloacta 43.6 ' 39.1 43.1 46.7 Pren vWlue of debtlGDP .. .. 22.1 Present value of dbepot .. 270.7 I 17545 1 1 1 131746 (averg anua rWth) -B Srazi GOP 3.1 1.2 4.1 2.0 4.6 GNP per capla 0.2 0.4 2.8 1.6 4.0 Uwerm nrd Export of goods and svis 10.6 8.5 -1.4 6.1 7.0 _ STRUCTURE of the ECONOMY (% of GDP) 1975 138 I338 am Owth19 16U f 1outputa nd _nvestu ) Agriculture 12.1 1 1.5 14.4 14.4 is Industry 40.2 45.3 36.5 36.4 to Manufachtn 30.3 33.7 23.6 .. * Services 47.7 43.1 49.1 49.2 e Private consumpton 86.5 65.6 64.9 65.7 .10 I Genrl govemnm consumption 10.6 9.9 15.9 16.1 Import of goods and sevIcs 11.5 7.1 7.8 7.9 O 137646 1384 1335 133 (Average annual I Growi ras of expoGtn and bImpou (%) Agrlciture 4.3 28 4.9 3.1 0o Industry 3.0 -1.1 2.1 2.3 Manufacturing 2.6 -1.5 2.1 .. . Servke 2.9 2.8 5.3 3,3 Prtate consumption 3.0 1.8 11; 0 4.1 o General govemment onsumption 1.2 0.7 2.4 0.8 63 94 " a Gro domestic ivstmnt -2.9 -0.8 9.4 0.0 40 Import of goods and services 4.0 8.9 36.8 5.9 Ev" Gross national product 2.5 1.1 4.2 2.9 E Note: 1996 dat are preeieninary estimates. Figure in lWlics ar for yers other thn toe speqfled. * The dwsmonds show four key inditors in the country (in bold) compared with It inome-group avere. If data am mesing, the diamrond wi be incomplee Brazil IUCES nd VW VE6 JaN FNOE 1978 1I 100 lo Coewe pIa63.0 226.9 7A 15.5 , Imptc GDP dekaw 33.9 231.7 74.0 11.1 ___ CumaIevJS . - 315 32A s so PM" vhmMdwbk .. .. 0.4 -0.1 OPIloe1 _uame .. - .4.0 43.9 TRADE U78t § INS 100 tU...N (Ian USS a"d hip kw"s (mI USS To et oris (fob) .. 25.63 46,606 47,746 Coffee .. 2607 1,1170 2060 Owfood .. 2.45 3.86 4.665 am*cu , , 1336 25,6 21.247 *_ Ttl Nd ) .. 13.153 40,663 63.*66 Fd .. .. 3.535 6.044 um L Fue and gy .. 6,176 4.64 5.752 Capi goodt 2.480 10.66 19i4104 E:vputptsWu.17m100) * 07 123 126 s 1 Is 03 0 3 " lnowt P401bidm(1067u100) . 7 124 125 *ft *Nte T em of (1& 67 u10 123 *103 101 SALANCE oFPA_Y__E (,, S L1Io w C t account banc *t GDP n %) EX D goo d erdvis 9.41S 27.713 47.060 49.56 S Impors of good nd ervIs 14.2 62 14,306 50.355 Rpiue boe -4.S00 10.785 4.346 4,797 Not' m . -2.106 -11.213 -15,410 -17.402 * Hot acrt tavs -10 1i 3.973 2,309 before dfficial capiw henelers -7,021 -412 -17?.702 -24.300 F hwk MM (nrz -m IANf 3 0,7711 32.f3 4 C4ange hi not ress 1,065 -1A414 -12.007 4.638 .4 Ree dudigPMd(MR USS 4.166 11i.13 51.460 509.66 Comion ret fhoeM/8) 3.0E-12 2.3E50 0.0 1.0 EXTERNAL OE8T an RESOURCE FLOWN (nVlon USS) Cpmobun of tta ddeK 103 (mKL USit Total deb ouw t an dbued V7.32 103.601 159.130 178.131 A C IBRD 1,045 5.24 6.036 5,676 a D42 IDA 0 0 0 0 1 TotCa dewt deqee 4n320 11.470 22l328 lBOR St 706 1,866 1.638 £9 IDA 0 0 0 0 Foreig 1.0 1.48 485 .. > 1 4 5 Copalnof neot re.ourwc fine Oftllciagunts I 24 64 Officreditors * 1.059 9s5 -1,378 PMae coddbs 4,213 149 0.927 Fmin d00inwthmn 1,302 1,345 4,859 . PorVtio oqulty 0 0 4,411 .. F Wodd Bank prgm Corfmn1ents 538 1.525 404 so A.-IRD E-Bla" OWburwnwnta 249 765 636 1,500 . - O a w n_d pp F-P pricpa rpayenlt 26 406 1,377 1,222 C-IMF G - Srdoen Netave 224 359 -530 278 Inbtt psyment 72 391 491 416 N0t tukfer 152 32 -1.031 -138 oe'eo_it Ec4mios L)28R7