Document of The World Bank Report No. T-6841-BIH TECHNICAL ANNEX BOSNIA AND HERZEGOVINA WAR VICTIMS REHABILITATION PROJECT APRIL 22, 1996 Human Resources Operations Division Central Europe Department Europe and Central Asia Region CURRENCY EQUIVALENTS (as of March 1. 1996) Unit of currency: Bosnia and Herzegovina Dinar (BHD) 100 BHD = US$0.67 ABBREVIATIONS AND ACRONYMS BH Bosnia and Herzegovina CBR Comimunity-Based Rehabilitation CEE Central and Eastern European CY Calendar Year CIDA Canadian International Development Agency DC Direct Contracting EBRD European Bank for Reconstruction and Development ERP Emergency Recovery Program ESDF Council of Europe's Social Development Fund EU European Union FY Fiscal Year (of the World Bank) GDP Gross Domestic Product GSP Gross Social Product IBRD International Bank for Reconstruction and Development IDA International Development Association IMF International Monetary Fund IS International Shopping MOH Ministry of Health NCB National Competitive Bidding NGO Non-Governmental Organization NS National Shopping OT Occupational Tlherapy PA Procurement Agent PIU Project Implementation Unit PT Physical Therapy PTSD Post-Traumatic Stress Disorders RS Republika Srpska SNCB Simplified National Competitive Bidding SOE Statement of Expenditures TA Technical Assistance TFBH Trust Fund for Reconstruction of Bosnia and Herzegovina UNHCR United Nations High Commissioner for Refugees USAID United States Agency for International Development WHO/EURO World Health Organization European Office FISCAL YEAR January 1 to December 31 BOSNIA AND HERZEGOVINA War Victims Rehabilitation Project Technical Annex Table of Contents A. BACKGROUND ...................... 1 The Health Care System and Health Status Prior to The War ....... . 1 Impact of The War on Health Status on the Health Care System .. . 2 Physical Disabilities ................ . 3 Psycho-Social Disabilities ................. 3 Infrastructure and Services for Rehabilitation ..................5 B. GOVERNMENT STRATEGY: FROM EMERGENCY TO DEVELOPMENT .............................. 7 Developing a Medium-Term Strategy .. 7 Immediate Interventions to Reduce the Burden of Disability ......... 7 C. BANK ASSISTANCE STRATEGY .............. 8 Health Sector Recovery Program ................. . 9 Bank-Supported Priority Interventions ............. 9 D. THE PROJECT ................................... 12 Project Objectives and Components ........ .. ............. 12 Detailed Project Description ............ ............... 13 Community-Based Rehabilitation Component ............... 13 Prostheses and Orthoses Production Component ..... ........ 19 Orthopedic and Reconstructive Surgery Component .... ....... 21 Project Implementation Support Component ....... ......... 22 Project Cost and Financing Plan ........... .............. 24 Environmental Aspects ............. ................. 27 E. INSTITUTIONAL ARRANGEMENTS AND IMPLEMENTATION . . 28 Project Organization . . .. 28 Project Implementation Arrangements ..................... 28 Project Implementation Schedule . . .. 32 Procurement Arrangements . . .. 32 Disbursements . . .. 35 Accounts, Auditing and Reporting . . .. 35 Supervision Plan . . .. 35 (Table of Contents, continued) F. PROJECT BENEFITS, ECONOMIC JUSTIFICATION AND RISKS 36 Project Benefits and Economic Justification ........ .......... 36 Project Risks ................ .................... 37 TABLES Table 1: Three-Year Assistance Program for Health Sector Recovery ... ..... 9 Table 2: Priority Health Services and Levels of Service Delivery ... ....... 11 Table 3: Community-Based Physical Rehabilitation Sub-Component Cost Summary .................................. 16 Table 4: Community-Based Psycho-Social Rehabilitation Sub-Component Cost Summary .................................. 18 Table 5: Prostheses and Orthoses Production Component Cost Summary ..... 21 Table 6: Orthopedic and Reconstructive Surgery Component Cost Summary . .. 22 Table 7: Project Implementation Support Component Cost Summary ... ..... 24 Table 8: Total Project Cost ................................. 25 Table 9: Financing Plan ................................... 27 APPENDICES 1. The Status of Orthopedic and Reconstructive Surgical Units 2. The Status of Prostheses Production and Maintenance Units 3. Organization of Rehabilitation Services 4. Cost Estimates and Disbursement Schedule 5. Project Procurement Arrangements and Plan 6. Project Implementation Schedule 7. General Procurement Notice 8. Summary Technical Specifications 9. List of Supporting Volumes and Documents in Project File MAP IBRD 27716 Technical Annex Page 1 of 37 A. BACKGROUND The Health Care System and Health Status Prior to the War 1. By the end of the 1980s, the contrast between the development of health care services and the uneven achievements in health status suggested that systemic problems were limiting further progress in health outcomes in Bosnia-Herzegovina. On the one hand, the system had achieved remarkable coverage and the use of high technology; on the other hand, some key health status indicators still showed low achievements. 2. Like most other formerly socialist economies in Central and Eastern Europe (CEE), Bosnia-Herzegovina had a well developed health system. The population enjoyed reasonable access to a large network of clinics, hospitals and public health facilities, financed largely through payroll taxes and general revenues. There were 5.8 beds per 1,000 population and 2.6 doctors per 1,000 population. Although these figures were average for CEE, they were higher than those of most other developing countries at similar income levels. Total health expenditure was around 6.5% of GDP in 1990, which was on the high side of the range encountered in the region. 3. Although substantial gains had been achieved in health outcomes during the two decades preceding the war, the indicators of health status showed a mixed picture. The infant mortality rate had declined from 56 per 1,000 live births in 1970 to 21 per 1,000 live births in 1991. But, partially due to the weak primary care network, the percentage of infants immunized against childhood illnesses in 1991 was less than in other European socialist economies, with the exception of the former USSR. While the age-standardized mortality rate for communicable diseases, maternal and perinatal causes (87 per 100,000 population) was worse than the average of 52 per 100,000 for other European socialist countries, the life expectancy of 73 years at birth was at the higher end of the range observed in the region. 4. The pre-war health system suffered from a number of problems. A supply- dominated approach to centralized planning had led to the proliferation of large hospitals and heavy reliance on specialized polyclinics, with relatively little attention to primary health care or family practice. The centralized decision-making process did not encourage strategic planning to achieve the most efficient use of resources. Instead, decisions were most often the result of bureaucratic bargaining, rather than a rational assessment of needs and available resources. Clinical decisions were not based on considerations of the effectiveness or costs of the desired interventions. Mental health services were concentrated in large hospitals, with prolonged admissions and few, if any, efforts to reintegrate patients into the community. Some patients, women in particular, were abandoned in hospitals by their families, on account of the social stigma associated with mental illnesses. Technical Annex Page 2 of 37 Impact of The War on Health Status and the Health Care Delivery System 5. The armed conflict has put an enormous toll on the health status of the population. Not only have the common indicators of health status showed a dramatic quantitative deterioration, placing BH at a level comparable to low-middle income economies, such as Tunisia, Paraguay or the Philippines, but the mix of diseases has changed significantly. This implies that the future health care interventions will have to respond not only to the increased size of the problem but also to the unusual blend of the current burden of disease. 6. The deterioration in living conditions, malnutrition, intense psychological stress and loss of access to basic health services have caused dramatic declines in the overall health status of the population, which are likely to be more severe in rural areas and isolated enclaves. Based on information from Sarajevo, the infant mortality rate is estimated to have doubled, reaching an average of 30 to 40 per 1,000 live births in urban areas. The incidence of serious congenital malformations rose from 0.7% to 2.1% of births during the war. Almost 25% of these malformations were anencephalus (absence of a brain) or hydrocephalus (excessive water in the brain), which could have been detected during the pre-natal period and managed appropriately, if access to, and functions of, diagnostic and treatment services had not been severely interrupted during the war. Similarly, premature births have doubled, while the average birth weight has dropped by more than 20%. The rate of perinatal mortality rose from about 15.3 per 1,000 live births before the war to 38.6 per thousand diring the conflict. Available data on morbidity show a two- to five-fold increase in the number of people affected by epidemics and communicable diseases (influenza, tuberculosis, hemorrhagic fever), with a surge in the number of fatal cases. 7. In the area of reproductive health, family planning, as reflected by contraceptive use, had never been given a high priority within the health care system of former Yugoslavia'. As a result, the incidence of induced abortion was traditionally high. With the onset of the war, the number of induced abortions increased significantly. Pre- and intra- war data for Sarajevo indicate that abortions increased from a ratio of one for every birth to at least two for every birth. The high rate of abortions, especially given the constrained medical resources, and the reduced capacity to sterilize equipment, have created the condition for subsequent low-grade infections and infertility. With the end of the conflict, particular attention will need to be given to primary prevention of unwanted pregnancies with contraceptives, as opposed to the dependency on abortion as a secondary prevention technique, as well to infertility counselling and clinical services. 8. Of particular importance to the choice and design of interventions, the war in BH has induced an unusual mix in the burden of disease. For the Federation alone, in addition to the estimated 250,000 persons killed, the total number of war-injured persons in BH is 'International Center for Migration and Health. ReDroductive Health and Pregnancv Outcomes Among Displaced Women. Report of the Technical Working Group. October 1995. Technical Annex Page 3 of 37 reported to be about 175,000, of which over 50% are seriously injured. Moreover, the incidence of stress disorders has increased dramatically on account of the war. The resulting disabilities will place a heavy long-term burden on health and social services in BH, because many of the injured and disabled will need long-term care, with physical and mental rehabilitation, in addition to their initial acute medical care. Physical Disabilities 9. Estimates and Consequences of Physical Disabilities. As of December 1995, 12,296 disabled persons were registered and estimates of persons requiring physical rehabilitation due to war injuries ranged from 40,000 to 70,000. The major causes of injuries are bullet and shrapnel wounds resulting in the following major impairment and disability groups (WHO/MOH, 1994): 3,000 to 5,000 amputations, 750 spinal cord injuries, 3,000 peripheral nerve injuries, 1,200 craniocerebral injuries, and an unspecified number of soft tissue injuries and fractures. The burden on children is enormous. It is estimated that more than 50,000 children have been wounded, half of them seriously. In the absence of effective rehabilitation, physically disabled persons will be unable to resume or commence economically productive activities and will constitute a substantial burden on the social support system. 10. Managing Physical Disabilities: Basic Principles. Physically disabled persons require one or more of the following, depending on the site and severity of their injuries and disabilities: (i) surgery to remove irreversibly damaged parts, to limit continued damage and to reconstruct parts of the body that remain viable; (ii) short-term hospital-based rehabilitation following surgery; (iii) alleviation of pain with medications; (iv) artificial limbs and devices to enable them to walk, use their arms and hands, as well as maintain healthy physical postures (prostheses and orthoses); and (v) non-hospital based rehabilitation to ease them into normal economic and social life. In addition, efforts will have to be made to ensure that major public buildings and facilities, as well as workplaces, are accessible to the physically disabled. Psycho-Social Disabilities 11. Increased Incidence of Post-Traumatic Stress Disorder (PTSD). The war has also taken its toll on the mental health of the population, with an estimated five-fold increase in the incidence of PTSD, affecting both adults and children. PTSD is a collection of short- term and long-term illnesses and disabilities caused by extremely distressing experiences such as physical violence, war, rape and torture. Patients may suffer from severely altered and labile moods, anxiety, depression, irritability and inability to function in seemingly normal situations -- in sum, incapacitation at the individual, family and social levels. PTSD is particularly severe when the victim perceives human malevolence as a cause of the stressful experience. Persons suffering from PTSD may persistently reexperience the distressing event, including recollections, dreams and acting as if the event were recurring. They may persistently avoid situations even remotely associated with the event. Causes and Technical Annex Page 4 of 37 consequences of PTSD are well documented, including studies following the Second World War and the Vietnam War, and are clearly relevant to the recent history of BH. Persistent reexperiences of war-related events are incompatible with a willingness to reconciliate with a former enemy. 12. Although it is difficult to gauge the extent of PTSD in BH, expert opinion suggests that at least 15% of the population may experience mental distress severe enough to require treatment. According to the Psychiatry Department of the Clinical Center in Sarajevo, the incidence of stress disorders is highest among adult males aged between 25 and 44 years. Some indication of the likely magnitude of PTSD in children is suggested by data from the area of Srebrenica, where 545 children were orphaned and 10,000 were left with only one parent. In addition to the soldiers who should soon return to civil life, initial surveys show that large proportions of women and children (70% to 80% in some areas) have witnessed war acts and atrocities, and have suffered psychological trauma likely to deeply imprint their future behavior. 13. Consequences of PTSD. The emphasis on rehabilitation of war victims is fully justifiable. PTSD severely impairs the victims' capacity to function normally, dramatically reducing their contribution to economic and social life. Its consequences include: (i) markedly diminished interest in, and ability to perform, significant activities (in young children, this results in impaired aptitude to learn and loss of acquired developmental skills such as language); and (ii) irritability and inability to concentrate in individuals who were apparently successful prior to the stressful event (diminishing adults' capacity to work productively). To prevent and/or limit the duration of these states of impaired function, PTSD can be successfully treated through combinations of medications, individual counselling and psychotherapy, group therapy and assistance with re-entry into normal life. 14. Other Disabilities. In addition to the war-injured population, there are those with mental and physical disabilities due to non-war related acute and chronic diseases, including developmental disabilities, neurological, musculoskeletal and cardiorespiratory disease and degenerative disease processes. Children, women, refugees and the elderly are particularly vulnerable members of the population due to isolation and breakdown of families and community support systems. The limited availability of health services, poor nutrition and limited rehabilitation services during the war have compounded these adverse effects. 15. Since 1992, the infrastructure of the health sector has been severely affected by war, resulting in major and persistent damage. The direct (damage or destruction due to shelling) and indirect (absence of maintenance and repair due to lack of resources) effects of the war have led to a collapse or loss of functionality of a significant part of hospitals, clinics and other health care facilities. The destruction of hospital buildings has led to the elimination of about 35% of beds and a loss of functionality of many others. Currently only about 7,700 hospital beds remain "active" throughout the Federation (three beds per 1,000 inhabitants, about half of the pre-war total). It is estimated that more than US$300 million Technical Annex Page 5 of 37 worth of medical equipment has been destroyed, in addition to the equipment transferred from civilian institutions to military hospitals during the conflict. Infrastructure and Services for Rehabilitation 16. Facilities for both physical and psycho-social rehabilitation, orthopedic surgery and prosthetics in BH are very limited in what they can offer to victims of the war. Most hospitals and primary health centers are unable to offer adequate services due to destruction of physical infrastructure, lack of water and electricity, absence of maintenance and repair, and (at best) intermittent supplies of drugs and consumables. Rehabilitative services are severely compromised by the lack of an explicit conceptual framework that could be modified in response to local variations among cantons, the limited availability of community rehabilitation resources, the lack of occupational therapy services, limited availability of equipment suitable for community and home use, and the absence of a reliable database on disability incidence and prevalence. 17. Physical Rehabilitation. Although the marked increase in the number of surgical patients resulted in overutilization of available equipment and instruments, the necessary maintenance could not be done due to a lack of supplies, spare parts and servicing. Most of the instrumentation needs replacement, much of the equipment needs repairs and all equipment needs regular service in the future. Additional instruments and equipment are needed to enable the hospitals to cope with the current and anticipated high demand for orthopedic and reconstructive surgery by war victims. The MOH's Working Group identified 10 hospitals which are expected to support the centers for community-based rehabilitation. Three of these hospitals have only general surgical departments while the other seven (the Clinical Centers in Sarajevo, Mostar and Tuzla, the State Hospital in Sarajevo, and the hospitals in Zenica, Bihac and Livno) already have orthopedic surgical departments. 18. Prior to the war, physical rehabilitation services, required on a relatively limited scale compared to current needs, were based in hospitals and specialized rehabilitation centers. Some of the hospitals with orthopedic and reconstructive surgical facilities also provided physical rehabilitation services. In addition, during the war, community-based rehabilitation (CBR) centers were established with the support of international humanitarian aid organizations. In Sarajevo there are five CBR centers; one CBR center is located in the dom zdravlja in Srebrenik, near Tuzia, and one center is located in Nemila, near Zenica. All but one of these centers have been supported with equipment, minor structural alterations and, importantly, education of personnel by Queen's University, Canada, with funding from the Canadian International Development Agency (CIDA) and a private donor. WHO is also currently supporting the operation of one CBR center in Mostar and plans to support seven additional centers throughout BH. Appendix 1 details the current situation of rehabilitation services. The specialized Institute of Rehabilitation at Ilidza, which was a clinical and educational center serving the Sarajevo area, was heavily damaged during the war and is no longer functional. Technical Annex Page 6 of 37 19. There is a shortage of social workers and prosthetics technicians, and occupational therapy is not available. Allied health personnel, including physical therapists and nurses, are trained at secondary school level from the age of 14 years. Some students go on to a higher level three-year program at medical high school. Programs for physical therapy are offered at the University Rehabilitation Institutes in Tuzla and Sarajevo. Education and training have been severely disrupted by damage to physical facilities, loss of and/or outdated equipment, lack of learning resources, textbooks and scientific journals and loss of teaching staff. There are no training programs for occupational therapists, and none for prosthetic and orthotic technicians. 20. Psycho-social Rehabilitation. Several organizations, including WHO, have developed projects in the major centers throughout BH for psycho-social support to the population affected by the war. The institution-based rehabilitation services have been insufficient to meet the needs of persons with disabilities, largely due to inaccessibility, now compounded by damage during the war. For example, the Neuropsychiatric Clinic (Hospital) in Sarajevo was shelled about 40 times and has suffered major damage. Many people live at a distance from the hospitals and transportation is inadequate. For those unable to get to outpatient facilities, minimal home visiting services are available in a few locations. In the absence of rehabilitation services in the communities to which patients can be referred for ongoing care, the pre-war and current institutional systems call for longer periods of inpatient treatment than necessary. In addition, institution-based care does not address the many social and functional aspects of reintegration into the community, including family life and employment. These issues are recognized by BH experts in psycho-social rehabilitation who have decided to de-emphasize the institution-based approach in favor of a community-based approach. 21. Psycho-social rehabilitation services are also severely compromised by a lack of staff through war casualties, migration, lack of sufficient training programs and lack of remuneration. Rehabilitation services are provided primarily by psychiatrists, physical therapists, and psychologists. 22. Production Capabilities for Prostheses and Orthoses. There are currently seven prostheses and orthoses production/maintenance units with different mandates, sizes and quality. These units have been established and are managed by different governmental and non-governmental organizations. With at least four production systems within BH (German, Italian, Russian and French), standardization has become a priority. Beyond improved coordination and standardization of systems, these production units require civil works (repairs, rehabilitation and partial reconstruction of existing premises), equipment and supplies to produce the needed quantity and quality of prostheses and orthoses, and skills development for their personnel to improve productivity and quality of output. The status of individual prosthetic/orthotic units is presented in detail in Appendix 2. Technical Annex Page 7 of 37 B. GOVERNMENT STRATEGY: FROM EMERGENCY TO DEVELOPMENT 23. With the end of the war, the health sector in Bosnia and Herzegovina faces a triple challenge: to continue to function on an emergency basis for the short- to medium-term; to undertake its recovery; and the transition to a modern efficient system. First, and for some time to come, the sector professionals will continue to live and work under emergency-type conditions. With still precarious living conditions, controllable epidemics will continue to break out, and health services will still handle larger proportions of emergency cases and war related injuries than any average country. Second, the reconstruction will have to start without delay. Especially in light of severe resource constraints, this puts an enormous pressure on sector authorities to prioritize activities and quickly plan large investments, in many cases without access to all relevant information. Third, and highly critical, the reconstruction effort must avoid rebuilding the unwieldy pre-war health system. This requires that much attention be given to the right balance between modern primary health care services and high quality but slimmer hospital services. Developing a Medium-Term Strategy 24. Initiating its response to the above-mentioned challenges, with the assistance of WHO/EURO, the Government of BH has outlined the guiding principles for the development of a national masterplan for the country's health sector recovery2. This document covers both the short-term reconstruction needs, and the future structure and functions of the health sector that could be achieved in the medium term. 25. Five pillars have been identified in the masterplan: (i) health system design (sector profile, health financing, administrative and organizational structures); (ii) human resources development; (iii) development of the infrastructure and basic essentials (physical reconstruction, medical equipment and supplies, pharmaceuticals, information systems); (iv) public health programs (communicable diseases and epidemics, non-communicable diseases, nutrition and health promotion, maternal and child health/ family planning, environmental health; and (v) rehabilitation (physical and psycho-social/mental). These also constitute the framework for the Task Forces that the Ministry has established or intends to establish for specifying the reconstruction and reform masterplan. lnmnediate Interventions to Reduce the Burden of Disability 26. A complete reform of the physical and psycho-social rehabilitation services constitutes one of the top priorities of the MOH strategy for the medium term. It is recognized, however, that immediate interventions to reduce the enormous burden of 2Federation Health Progran. Health Reform and Reconstruction Program of the Federation of Bosnia and Herzegovina. Ministry of Health. January 1996. Technical Annex Page 8 of 37 disability associated with the war require the formulation of a conceptually sound and implementable national program. Accordingly, in early February 1996, the MOH established a Technical Working Group of national experts in physical and psycho-social rehabilitation with the mandate to develop a comprehensive National War Victims Rehabilitation Program. The program, which is fully consistent with WHO's approach to community-based rehabilitation, was prepared with the assistance of the World Bank and the technical support of the Center for the Advancement of Community-Based Rehabilitation of Queen's University3, which has implemented community-based rehabilitation services during the war in BH. During the Bank's mission in February 1996, the Program was thoroughly assessed. It constitutes a rational, comprehensive and cost-effective plan of actions for addressing rehabilitation needs in BH. 27. Further, the preparation of such a program carries a lot of promise for the future development of the health care system in BH. First, the concept on which the program is based constitutes a clear departure from the pre-war system. Physical and psycho-social rehabilitation services are de-institutionalized. Hospital services are not excluded from the program, they are an integral part of it. Although they are no longer the centerpiece, they are the natural continuation of the community-based rehabilitation services, their natural complement within a well thought-out referral system. Second, through the community- based services, a modem concept of primary health care is being promoted, and it offers a natural platform for the implementation of the medium-term reform objectives of the MOH. In addition to its health, economic and social benefits, the CBR approach provides a timely opportunity to initiate the transition of the health system from the pre-war reliance on cumbersome and expensive hospitals to a prudent combination of sub-hospital level basic health care and a high quality, streamlined hospital level. The investments in limited civil works (remodelling/repairs of existing structures), training of personnel and supply of equipment would, upon reductions in the needs for rehabilitative services, be readily adaptable to other primary care services, the specifications of which would be determined during implementation of the National War Victims Rehabilitation Program. The investments in orthopedic and reconstructive surgical units are integral parts of essential hospital services, which would be further developed as part of the national reconstruction and reform efforts. C. BANK ASSISTANCE STRATEGY 28. The Bank's assistance strategy parallels and supports the Government's efforts. The first step has been to gather the needed information in order to articulate, together with the authorities of Bosnia and Herzegovina, an overall sector recovery program. Within the broad framework of the recovery program, the second step in Bank assistance has been and remains 3Supported by the Canadian International Development Agency (CIDA). Technical Annex Page 9 of 37 to help the Federation MOH develop its policies and specific priority programs for reconstruction. Finally, the Bank, together with the international donor community, is committed to supporting the financing and implementation of these programs through a series of operations that are presented below. Health Sector Recovery Program 29. A Recovery Program for the Health Sector of the Republic of Bosnia and Herzegovina, estimated at US$540 million has been submitted for consideration to the international donor community. This program is part of the US$5.1 billion reconstruction program that the Bank has been jointly developing with the Government and the donor community. Out of this, estimates for the health sector recovery program for the Federation of Bosnia and Herzegovina amount to US$440 million. The program encompasses all priority areas that require immediate attention and support, in order to stop further deterioration in the health status of the BH population and progressively rehabilitate the health services delivery system. The Recovery Program also supports the efforts needed to initiate structural reforms, thus guaranteeing the sector's sustainability in the recovering economy of Bosnia and Herzegovina. Table 1: Three-Year Assistance Program for Health Sector Recovery (commitments in US$ million) Category 3-Year First Year Requirements Program Budget Support for Recurrent expenditures 200 120 of which * salaries (50) (30) * drugs and supplies (150) (90) Public Health Interventions 17 8 Rehabilitation Programs for War Victims 20 10 Reconstruction and Rehabilitation 275 130 of which * Physical Rehabilitation (150) (75) * Equipment (125) (55) Sector Reforms 8 4 Program Management 20 8 TOTAL 540 280 Bank-Supported Priority Interventions 30. In the short term, the Bank will support a series of operations that cost-effectively address the most relevant and pressing health issues with which BH is confronted. The overall objective will be to minimize lost productivity and to alleviate suffering by reducing the burden of disease on the most at-risk segments of the population, namely the direct Technical Annex Page 10 of 37 victims of the war, and the women and children of BH. Improvements in the areas presented in Table 2 below will, however, extend much beyond these target groups. The entire population of BH will benefit from the cost-effective health services the proposed operations are intended to support, as they constitute the initial vehicles to carry out the fundamental changes required by the BH health care system. The overall health sector recovery program includes the entire State of Bosnia-Herzegovina. Contacts have been established with the health authorities in the Republika Srpska (RS). Exchange of documentation has also occurred and it is expected that further dialogue will be established and project preparation initiated. Nevertheless, this first operation concerns only the Federation because it was not possible at the time of appraisal to assess reconstruction needs, health programs and institutional capacity in the Republika Srpska. The appraisal was based upon information contained in the National War Victims Rehabilitation Program which was prepared by the Federation Ministry of Health (MOH). Officials of the Republika Srpska have expressed interest in the project approach, and are preparing information and proposals on needs for war victims rehabilitation, in the expectation that future projects could support these actions. Technical Annex Page 11 of 37 Table 2: Priority Health Services and Levels of Service Delivery Level(s) of Priority Services Health Care System Rehabilitation of Accident and Reproductive Child Health Public Health War Victims Emergency Health Tertiary Care Orthopedic and Treatment of all Specialized Neonatal and Health promotion Institutions reconstructive traumatized, obstetrics and pediatric (Clinical Centers) surgery (referrals including referrals gynecology. intensive care from cantons) of trauma (referrals (referrals complications from cantons) from cantons) Short-term post- cases from operative cantonal hospitals physical rehabilitation Secondary Orthopedic and Essential Obstetrics & Neonatal care Health promotion Facilities reconstructive diagnostic and gynecology: Cantonal/ General surgery treatment services (referrals Pediatric in- Hospitals from sub- patient and Short-term post- hospital level) out-patient operative services physical (referrals rehabilitation and from sub- cases which hospital level) cannot be treated on an out-patient basis Acute care psychiatry Sub-Hospital Community- First aid Normal Pediatric out- Immunization. Level based General practice deliveries patient - Polyclinics rehabilitation Communication Prenatal care services Health - Ambulanta - physical Health promotion Family promotion - mental Planning Technical Annex Page 12 of 37 31. Three Bank-supported operations are envisioned in the early stages of assistance to the health sector of BH. First in the series is the proposed War Victims Rehabilitation Project which is detailed below. The rationale for beginning with this Project has several elements, among which are the desirability of: (i) selecting an intervention which could be prepared rapidly and be ready for Board Presentation during the second quarter of 1996; (ii) focussing on a self-contained, targeted set of activities; (iii) selecting a set of activities with obvious and direct links to the conflict and which could unambiguously be considered as urgent both politically and economically; (iv) selecting a set of activities whose rapid implementation would not, on the one hand, require major prior policy decisions and on the other impose rigidity on the system which might impair future reforms; and (v) starting with a rather modest operation (US$30 million) in light of uncertainties concerning inputs from other donors. 32. Subsequent operations would address the other priority service needs presented in Table 2, at the cantonal hospital and sub-hospital levels, respectively; these projects would either include RS, or separate parallel operations would be developed. It is first envisioned to develop an Essential Hospital Services Project that would focus on the needs of the hospital sub-sector. The rationale is based on several factors, including: (i) the need to address quickly the most pressing hospital issues within a rational framework, thereby reducing the risk that uncoordinated, expensive and possibly unneeded investments in the hospital sub-sector would jeopardize the overall sector sustainability; (ii) the need for more time to resolve basic questions about the future conception and organization of sub-hospital services; and (iii) the assumption that direct donor assistance would continue to be available for some time for basic health services, as has been the case during the war, while the strategic options for the reconstruction of a modem basic health care system were being considered. The Essential Hospital Services Project would be ready for Board presentation during the third trimester of 1996. 33. The third operation, for which preparation would begin during the third quarter of 1996, would be the Basic Health Services Development Project, focussing on the sub-hospital level. It would also tentatively support implementation of the most urgent Health Financing Reforms that would initially be developed under the Structural Adjustment Credit (SAC), as well as the early steps for developing a critically needed pharmaceutical policy in BH. D. THE PROJECT Project Objectives and Components 34. The ultimate objectives of the War Victims Rehabilitation Proiect are to facilitate the reintegration of war victims into economically productive activities and normal social life, and to avoid the heavy costs of lost productivity and sustained disruption of the social fabric of BH. Specifically, the Project is aimed at reducing the burden of physical and Technical Annex Page 13 of 37 psycho-social disabilities through targeted and cost-effective rehabilitation services. In pursuit of these objectives, the Project will include the following components: a. Community-Based Rehabilitation (estimated base cost US$12.6 million). This component will address the rehabilitation needs of physically injured and psychologically disabled war victims. b. Prostheses and Orthoses Production (estimated base cost US$6.0 million). This component will support the production and maintenance of quality of prostheses and orthoses in three production units and five maintenance units. c. Orthopedic and Reconstructive Surgery (estimated base cost US$8.5 million). This component will improve the availability and quality of essential orthopedic and reconstructive surgical services in three Clinical Centers and four Cantonal hospitals. d. Project Implementation Support (estimated base cost US$1.8 million). The Project will support the establishment and functions of a Project Implementation Unit to manage the Project's activities. 35. One of the most pressing issues faced by health authorities at the Federation and cantonal levels is the need to restore salaries for health service professionals. However, financing constraints prevented inclusion of salaries for health service professionals under the proposed Project. If the current low level of remuneration of health professionals and the irregularity of payments remain unaddressed, there is a substantial risk that the rate of attrition of health professionals, especially the best qualified, could increase sharply, and/or that professional commitment could erode. This could have serious negative effects on the quality of health services delivered in general, and on the project-supported activities in particular. Additional donor financing devoted to supporting/complementing health professionals' salaries could help alleviate this problem. Mechanisms to effectively allocate and manage these potential resources are under preparation, but sources of such financial assistance are yet to be identified. Detailed Project Description Community-Based Rehabilitation Component (estimated base cost US$12.6 million) 36. Conceptual framework. The community-based rehabilitation (CBR) center will form the core of this component. The location will depend on the demographics of each area, but CBR centers will be located within existing health centers (dom zdravlias) and/or ambulantas. The Project will not support the construction of new structures, but will instead adapt existing structures to perform new functions. This approach is based on a conceptual Technical Annex Page 14 of 37 framework of a continuum of essential diagnostic and treatment services provided at various levels of the health care system. Injured or disabled persons live in the community, hence the CBR center is particularly suited to serve as the entry point for patients entering the rehabilitation system. The continuum of services, whose main features are illustrated in Appendix 3, is organized as follows: (i) the patient enters the system at the CBR center; (ii) diagnostic and curative services are delivered at the CBR center; (iii) if necessary, the patient is referred from the CBR center to the orthopedic department or the psychiatric department of the hospital, and/or the prostheses and orthoses production and maintenance units; (iv) diagnostic and curative services are delivered in hospitals and prostheses/orthoses production and maintenance units; (v) the patient returns to the CBR center and then back home; and (vi) the patient is followed up, according to need, by means of home visits. The CBR approach is strikingly different from the pre-war emphasis on prolonged hospital admissions for persons with mental illness and physical disabilities. It focuses on delivering effective services and achieving demonstrable outcomes using cost-effective interventions to facilitate reintegration of patients into economically active and socially viable lives. Although the project design specifies the conceptual framework and the functions of CBR centers, context- specific modifications are required to operationalize the CBRs in the diverse cantons of the Federation. The Project will support the implementation of regional networks of community- physical rehabilitation services throughout BH. Community-Based Physical Rehabilitation Sub-Component 37. Design and Functions. The Project will provide priority rehabilitative physical therapy and occupational therapy for an estimated 40,000 to 70,000 war-injured persons and an estimated 2% to 3 % of the BH population who are physically disabled from non-war related causes. Accordingly, the Project will improve rehabilitative services in the three Clinical Centers existing in BH and five Cantonal Hospitals, and will support the development and operation of a network of 30 CBR centers. These include the eight existing centers (that will be further reinforced and supported) and three additional centers (possibly Tuzla, Gorazde, Tomislavgrad/Mostar cantons) planned by the MOH with the support of Queen's University/CIDA. Also included are the seven additional centers that WHO plans to provide with technical support. Plans and decisions regarding the locations of new centers and the amount of upgrading required by existing centers will be coordinated by the Project Implementation Unit (PIU) to avoid duplication and to integrate NGO inputs. 38. Civil Works. Equipment and Supplies. The Project will provide civil works for repairs/remodelling, furniture, equipment and supplies to establish 22 CBR centers, upgrade the eight existing ones and support incremental operational expenditures in all of them. Equipment and supplies will include those required for exercise therapy/kinesiotherapy; electrotherapy equipment which may be used at the beneficiary's home; essential pharmaceuticals; educational literature for patients and families; and filing cabinets, computers, fax modems and printers for data collection, information presentation, record keeping and communications. Funds will be provided to cover incremental recurrent operating needs including electricity, water, gas supply; telecommunications services; Technical Annex Page 15 of 37 maintenance of physical space and transportation costs for the team in charge of outreach activities (fuel for personal vehicle or taxi fares). The Project will provide limited civil works, equipment and essential pharmaceuticals and supplies in the three Clinical Centers and five Cantonal Hospitals to provide acute rehabilitative care following surgical intervention. 39. Personnel and Training. The Project will support training in the principles and practice of community-based rehabilitation and enhancement of clinical skills for approximately 240 professionals involved in physical rehabilitation. Training will be delivered at the university, hospital and CBR center levels. Learning resources will be provided at all levels, for professionals delivering services and for persons with disabilities, their families and volunteer social workers. Optimally, each CBR clinic/outreach service should be staffed with one physician, four physiotherapists, one occupational therapist, one nurse and one receptionist (both part time). The current shortage of clinicians, particularly in smaller locations at a distance from the training centers, could initially create some difficulties in finding appropriate numbers of qualified personnel to staff the CBR clinics. This should progressively be offset through the training and retraining of additional personnel. Technical Annex Page 16 of 37 Table 3: Community-Based Physical Rehabilitation Sub-Component Cost Summary Unit cost Total Base Item Unit Quantity (US$) Cost (US$) Investment Costs Rehabilitation of Physical CBR centers per unit 22 45,000 990,000 Rehabilitation of Physical Rehab. Dept. of hospitals per unit 8 15,000 120,000 Essential equipment for Physical CBR centers per unit 22 47,500 1,045,000 Essential equipment for Phy. Rehab. Dept. of hospitals per unit 8 42,500 340,000 OT/PT Equipment for Sarajevo, Tuzla & Mostar Univ. per unit 3 68,813 206,440 Office equipment for Physical CBR centers per unit 22 7,500 165,000 Office equip. for Phy. Rehab. Dept. of hospitals per unit 8 4,500 36,000 Learning resources for Physical CBR centers per unit 30 4,000 120,000 Learning resources for Sarajevo, Tuzla & Mostar Univ. per unit 3 25,333 76,000 Furniture for Physical CBR centers per unit 30 8,000 240,000 Furniture for Sarajevo, Tuzla and Mostar Univ. per unit 3 5,000 15,000 International TA m/m 50 15,000 750,000 Health Promotion Study lump sum 300,000 Local TA m/m 18 1,000 18,000 Local training m/days 450 100 45,000 Overseas training m/m 12 7,500 90,000 Recurrent costs Operational cost of CBR centers per unit 30 38,000 1,140,000 Pharmaceutical for CBR centers per unit 30 30,000 900,000 Supplies & consumables for CBR center per unit 30 15,000 450,000 Pharmaceuticals for Phy. Rehab. Dept. of Hospitals per unit 8 18,000 144,000 Total Base Cost 7,190,440 m/rn = man months Technical Annex Page 17 of 37 Community-Based Psycho-Social Rehabilitation Sub-Component 40. Design and Functions. A priority for this sub-component is to support the delivery of services to those suffering from post-traumatic stress disorder (PTSD) and other less serious psychological illnesses, thus preventing chronic disability as well as promoting social and professional reintegration. The Project will support the development and operation of a network of 30 CBR centers for treatment of PTSD. It will provide acute psychiatric care in hospitals and technical support to the network of CBR centers by upgrading rehabilitative services in 14 hospitals. This sub-component will provide diagnostic services and treatment, including individual psychotherapy, family counselling and family psychotherapy, home visits, behavioral and conditioning techniques, medications, psycho-social support systems and group therapy with others who have shared similar traumatic experiences. 41. Civil Works. Equipment and Supplies. The Project will provide civil works for repairs/remodelling, equipment, technical assistance, training, audiovisual equipment for private and group counselling, as well as incremental recurrent costs to establish a network of 30 CBR centers. It will provide limited civil works for repairs/remodelling, equipment, supplies and essential pharmaceuticals to strengthen acute psychiatric care in 14 hospitals. 42. Personnel and Training. The Project will support the training of 240 professionals in the principles and practice of community-based psycho-social rehabilitation and skill development for personnel. The proposed approach to service delivery is a major departure from the pre-war situation, and it is clearly one with which the workers are not familiar. As a result, external technical assistance will be required to train workers in: (i) the subject matter of community-based psycho-social rehabilitation; (ii) the organization of service delivery in the new system; (iii) effective techniques for communicating with patients; (iv) the management of individual and group counselling sessions; and (v) self-assessment methods for improving service delivery. Each center delivering psycho-social rehabilitation services would be staffed with one psychiatrist, four nurses, one social worker, one occupational therapist, and one case worker. Technical Annex Page 18 of 37 Table 4: Community-Based Psycho-Social Rehabilitation Sub-Component Cost Summary Unit Quantity Unit Total Base Item cost Cost(US$) l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (U S $ ) Investment Costs Rehabilitation of Psycho-social CBR centers per unit 30 45,000 1,350,000 Rehabilitation of Rehab. Dep. of hospitals per unit 14 15,000 210,000 Equipment for Psycho-social CBR centers per unit 30 8,500 255,000 Equipment for Psycho-social. Rehab. Dept. of hospitals per unit 14 15,000 210,000 Equipment for Psycho-social CBR centers per unit 30 20,000 600,000 Equipment for Psycho-social Rehab. Dept. of hospitals per unit 14 7,500 105,000 Learning resources for Psycho-social CBR centers per unit 30 4,000 120,000 Furniture for Psycho-social CBR centers per unit 30 5,500 165,000 International TA m/m 30 15,000 450,000 Local TA m/m 18 1,000 18,000 Local training mr/day 450 100 45,000 Recurrent costs Operational cost of CBR centers per unit 30 32,000 960,000 Pharmaceutical for CBR centers per unit 30 18,000 540,000 Supply & consumables for CBR centers per unit 30 5,000 150,000 Pharmaceuticals for Psycho-social Rehab. per unit 14 18,000 252,000 Dept. of hospitals Total Base Cost 5,430,000 m/m = man months m/day = man days 43. Selection criteria for beneficiary health facilities under the Community-Based Rehabilitation Component. The criteria for selection of the CBR centers providing physical and psycho-social rehabilitation under the Project will be as follows: (i) each CBR will be located in an existing health facility, preferably a dom zdravlja (although physical CBR centers and psycho-social CBR centers may be located in the same building, they will not be in the same physical space); (ii) one CBR center will serve a population of approximately 70,000 to 90,000 people; (iii) the CBR centers will be located in the largest municipalities of the canton, unless there are compelling and transparent reasons to locate them elsewhere; (iv) Technical Annex Page 19 of 37 no municipality will have more than one CBR center, except on the basis of populations in excess of 90,000; and (v) the canton and/or municipality must be in support of the location. 44. Appropriate clinical practice requires that the locations of post-surgical short-term therapy be the same as the locations of the surgical facilities. The criteria for selection of hospitals to provide acute care rehabilitation are as follows: (i) the hospitals must have remained active throughout the war (this criterion is intended to prevent indiscriminate reconstruction of facilities that were eliminated by the war; (ii) each hospital will serve a population of approximately 300,000 to 350,000 people; (iii) the hospitals must have had physical rehabilitation facilities before the war; (iv) each hospital's location must be such that it can support a network of three or four CBR centers; and (v) no municipality will have more than one project-supported hospital with physical rehabilitation facility. 45. As for the hospitals supporting psycho-social rehabilitation activities, criteria for selection are as follows: (i) the hospitals must have remained active throughout the war (this criterion is intended to prevent indiscriminate rehabilitation of facilities that were destroyed during the war); (ii) each hospital will serve a population of approximately 180,000 people; (iii) each hospital must have delivered acute psychiatric services before the war; (iv) each hospital's location must be such that it can support a network of three or four CBR centers; (v) no municipality will have more than one project-supported hospital with acute psychiatric care facility. Prostheses and Orthoses Production Component (estimated base cost US$6.0 million) 46. The Project will support the production of good quality prostheses and orthoses in three production units related to the three Clinical Centers orthopedic departments. In addition, five maintenance/service units will also receive support. The production and maintenance units currently function under a variety of ownerships (government and NGOs), receive material and technical support from various sources, and use a variety of uncoordinated production techniques and standards. The criteria for selecting the units to be supported by the Project are the following: (i) ownership by the municipal, canton or Federation Government, or official collaboration with, and recognition by, one of these levels of government; (ii) the unit must be established; (iii) the location of the unit must be such that it is within the same municipality or canton as a project-supported orthopedic and reconstructive surgical unit and its associated network of CBR centers; (iv) the unit must sign a commitment to upgrade and or/change to standardized production methods; (v) the unit's selection must be formally approved by the MOH; (vi) no municipality or canton will have more than one project-supported prostheses and orthoses production unit; and (vii) no municipality or canton will have more than one project-supported prostheses and orthoses maintenance unit. The estimated target population is 3,000-5,000 known amputees, plus new cases anticipated due to injuries from land mines and non-war related accidents. 47. Civil Works. Equipment and Supplies. The Project will provide limited civil works, machinery and raw materials to the specified production units. In one of the Technical Annex Page 20 of 37 production units (to be selected by the Ministry of Health with review by the Bank), the Project will provide equipment and supplies to develop a capacity for the production of upper limb prostheses. 48. Capacity building. The Project will provide in-service training for approximately 75 workers through external technical assistance. Training will emphasize practical skills, coordination and standardization of production systems. Following detailed assessments of each production/ maintenance unit to be upgraded, the Project would provide technical assistance for the introduction of modem production techniques. In Neretva, for example, the production process currently has up to six persons involved in the making of one prosthesis. This means that no one can take full responsibility in the rehabilitation process of a particular patient and the patient has no direct "partner" to address in this important part of the physical rehabilitation process. There is, therefore, an urgent need for training and introduction of modem production techniques. External technical assistance is required and will be provided to facilitate implementation of this component, focussing on: (i) the use of efficient production techniques; (ii) improvements in the quality of prostheses and orthoses; and (iii) the standardization of production systems by the MOH and the Professional Team (para. 59). A major reduction of the existing personnel and concurrent recruitment of enthusiastic young technicians should be done in order to increase productivity. Technical Annex Page 21 of 37 Table 5: Prostheses and Orthoses Production Component Cost Summary Unit cost Total Base Item Unit Quantity (US$) Cost (US$) Investment Costs Rehabilitation of P&O Production units lump sum 830,000 Rehabilitation of Maintenance units per unit 5 25,000 125,000 Essential Equip. for P&O Produc units lump sum 345,000 Essential Equip. for Maintenance units per unit 5 70,000 350,000 Protheses&Raw materials for P&O units lump sum 2,156,000 Protheses&Raw materials for maintenance units per unit 5 35,000 175,000 PC and Printer for P&O production and maintenance units and MOH piece 15 4,500 67,500 Photocopy machine for MOH piece 1 3,000 3,000 Wheel-chair accessible minivans piece 3 25,000 75,000 International TA m/m 30 15,000 450,000 Local TA m/m 12 2,500 30,000 Local training lump sum 52,000 Recurrent costs Operational cost of P&O units lump sum 115,000 Operational cost of maintenance units per unit 5 5,000 25,000 Supply and materials P&O units lump sum 1,056,000 Supply & materials for per unit 5 35,000 175,000 maintenance units Total Base Cost ________________ 6,029,500 & 0 = Prostheses and Orthoses Orthopedic and Reconstructive Surgery Component (estimated base cost US$8.5 million) 49. This component will upgrade essential orthopedic and reconstructive surgical services in the three Clinical Centers and four Cantonal Hospitals, to be selected according to the following criteria: (i) the hospitals must have remained active throughout the war (this criterion is intended to prevent indiscriminate rehabilitation of facilities that were destroyed by the conflict; (ii) each hospital will serve a population of approximately 300,000 to 500,000 people; (iii) the hospitals must have had orthopedic and reconstructive surgical facilities before the war; (iv) each hospital's location must be such that it can support a network of three of four CBR centers; and (v) no municipality or canton will have more than one project-supported hospital with an orthopedic and reconstructive surgical facility. 50. Civil works. Equipment and Supplies. The Project will provide limited civil works, surgical instruments, supplies and pharmaceuticals to enable the selected orthopedic and reconstructive surgical units to function effectively. Technical Annex Page 22 of 37 51. Personnel and Training. The Project will provide training for approximately 56 professionals providing orthopedic and reconstructive surgical services. From each of the hospitals, a team of two orthopedic surgeons, one anesthetist and one theater nurse will receive in-service training in centers of excellence abroad during the Project. The training would be of a duration of about three months. By this means the entire team would learn the modern surgical, anesthetic, post-operative and intensive care techniques which they would apply in their hospitals after their return and which they would then teach to the rest of the hospital staff using the new instruments and equipment to be provided by the Project. Table 6: Orthopedic and Reconstructive Surgery Component Cost Summary Unit cost Total Base Item Unit Quantity (US$) Cost (US$) Investment Costs Rehabilitation of O&R Units lump sum 1,300,000 Essential Equipment for O&R lump sum 4,400,000 units Wheel-chair accessible minivans piece 7 25,000 175,000 Overseas training (short-term) m/m 168 3,000 504,000 Recurrent costs Surgical supplies for 7 O&R units lump sum 2,100,000 Total Base Cost 8,479,000 rn= Man months Project Implementation Support Component (estimated base cost US$1.8 million) 52. Given the very tight fiscal position of BH during the initial period of recovery from the war, support would be provided to cover all required foreign and local costs of project management as set out in the table below. This would include all needed investments (civil works, office equipment, technical assistance and training) as well as recurrent expenditures for two years of operation. Since the required management capacity is currently not available in the MOH, a strong and dedicated Project Implementation Unit (PIU) will be created within the MOH. Necessary salary cost and other related operational expenditures will be covered under the Project to facilitate the functioning of PIU. 53. Experiences in a number of other CEE countries have shown weak implementation capacities in ministries of health. This is equally true of Bosnia and Herzegovina, where the MOH has no history of implementing Bank-supported projects and is poorly equipped to fulfill the responsibilities for managing a quick-disbursing operation. In light of these considerations, the PIU will be adequately staffed and supported to enable it to function Technical Annex Page 23 of 37 effectively and efficiently (specific needs and arrangements for technical assistance to support the PIU are described in Section E, "Institutional Arrangements and Implementation"). The PIU will consist of a project director to manage and coordinate the implementation of the Project; a procurement specialist to supervise tendering, purchasing and delivery of goods; an accountant to maintain project financial records; an architect to coordinate and supervise civil work activities; and administrative support staff, secretaries and translators. This core staff will constitute the PIU "Technical Team" which will establish linkages between the Federation MOH and Canton Administrations to ensure the timely implementation of the Project. This approach would contribute to the development of an effective management capacity in the MOH. A team of experts, comprised of members of working groups who prepared the project proposals, will constitute the "Professional Team". Further details regarding project organization are provided in paras. 58 - 59. Table 7: Project Implementation Support Component Cost Summary Unit cost Total Base Item Unit Quantity (US$) Cost(US$) Investment Costs Upgrading of Project Office lump sum 115,000 Office Equipment for PIU PC and printer piece 4 4,500 18,000 fax, telephone line piece 1 1,500 1,500 photocopy machine piece 1 3,000 3,000 Car for PIU piece 1 18,000 18,000 Furniture lump sum 20,000 Local and International TA - Civil works management lump sum 252,000 - Procurement services lump sum 867,220 - Local management staff mi/m 193 354,000 Overseas training m/m 3 7,500 22,500 Local training days 225 100 22,500 Recurrent costs Operational cost of PIU monthly 24 2,000 48,000 Office supplies and materials for PIU monthly 24 3,000 72,000 Total Base Cost 1,813,720 in/in = man months Technical Annex Page 24 of 37 Project Cost and Financing Plan 54. Project Cost. The estimated total cost of the Project is US$30 million equivalent, including physical contingencies of 3% on goods, technical assistance, training and recurrent costs, and 7% on civil works. No price contingencies have been included given the expected short disbursement period of this emergency Project. Investment costs (US$20.4 million base cost) covering civil works, essential medical and production equipment and prostheses, office equipment, furniture, vehicles, technical assistance, overseas and local training constitute 70% of the total base cost. Recurrent costs (US$8.1 million base cost), including medical supplies and materials, office supplies and materials, operating costs of facilities (including electricity, heating, transportation, travel and accommodation expenses) constitute 30% of the total base cost. Detailed cost tables are found in Appendix 4. Technical Annex Page 25 of 37 Table 8: Total Project Cost (US$ thousand) Expenditure Category CBR Prostheses Orthopedic Project Program &Orthoses & Reconst. Implem. Total Production Surgery Support Investment Costs Civil Works 2,670.00 955.00 1,300.00 115.00 5,040.00 Equipment & Materials Essential Equipment 2,056.00 695.00 4,400.00 7,151.00 Prostheses&Raw 2,331.00 2,331.00 Materials. 906.00 Office Equipment 316.00 71.00 23.00 999.00 Learning Resources 420.00 316.00 Furniture 20.00 440.00 Vehicles 75.00 175.00 18.00 268.00 Technical Assistance International 1,200.00 480.00 252.00 1,932.00 Local 36.00 1,221.00 1,257.00 Educ. & Promotion 300.00 300.00 Training Overseas Training 90.00 504.00 23.00 616.00 Local Training 90.00 52.00 23.00 165.00 Recurrent Costs Operational Expenses 2,100.00 140.00 48.00 2,288.00 Supply and Materials 2,436.00 1,231.00 2,100.00 72.00 5,839.00 Total Base Cost 12,621.00 6,029.00 8,479.00 1,814.00 28,942.00 Physical Contingencies 485.00 220.00 306.00 58.00 1,069.00 Total Project Cost 13,106.00 6,249.00 8,785.00 1,872.00 30,011.00 55. Financing Plan. The Government of Bosnia and Herzegovina would be the recipient of the funds to be provided by various donors. To proceed quickly with implementation, a phased financing formula is proposed. Grant financing of US$5.0 million from the Trust Fund for Bosnia and Herzegovina would be used to support initial project implementation prior to Bank Group membership. Under the same documentation, Board approval will be sought on a no-objection basis for additional financing of US$5.0 million on IDA terms, as soon as IDA lending to Bosnia and Herzegovina commences. Co-financing in the amount of US$20.0 million equivalent is being sought from the donor community. The Government of Technical Annex Page 26 of 37 Italy has announced its intention to co-finance the Project in the amount of US$3.2 million equivalent. Discussions are far advanced and agreement in principle has been reached with the Council of Europe's Social Development Fund (ESDF), for co-financing of the Project in the amount of US$5.0 million. In both cases, the details of the agreements will be finalized after the Second Donors' Conference for Bosnia and Herzegovina in Brussels in April, 1996. The Governments of Canada and of several European countries, as well as the European Union have also expressed strong interest in co-financing the Project, and these co-financing prospects should be firmed up following the Brussels Conference. If the mobilized resources exceed US$20 million, it would be highly desirable to increase the scope of the Project to include supplemental salary payments for health professionals. Provision for these payments would be added to this Project or to the subsequent Essential Hospital Services Project if the necessary donor financing -- amounting to about US$10 million over a twelve-month period - - becomes available, and if the MOH develops a feasible plan, acceptable to both partners of the Federation, for making these payments. If IDA financing and/or other needed co-financing were not available for any reason following approval of the initial grant, the project scope would be scaled down, with priority given to the Community Based Rehabilitation services and the most urgent of the other planned activities. Such a reduction would have an impact on the overall availability of rehabilitation services throughout the country, but would not affect the Project's overall viability. The predominance of Bank financing for Project Implementation Support is in recognition of the importance of this component for ensuring successful implementation (see Project Risks, para. 93), and the fact that there has been no pledge of assistance for this component from non-Bank sources. Technical Annex Page 27 of 37 Table 9: Financing Plan* (US$ million) CBR Prostheses & Orthopedic & Project Total Cost Program* * Orthoses Reconst. Implementation Production Surgery Support Trust Fund for 4.0 0.0 0.0 1.0 5.0 Bosnia & Herzegovina l IDA 1.0 2.0 1.9 0.1 5.0 Government of 1.0 1.5 0.7 0.0 3.2 Italy ESDF 2.0 1.0 2.0 0.0 5.0 EU 0.0 0.0 0.0 0.8 0.8 Donors to be 5.1 1.7 4.2 0.0 11.0 identified Total Project 13.1 6.2 8.8 1.9 30.0 Cost The proposed allocations among project components are only tentative since donor co- financing has not been confirmed. * * CBR Program: Community-Based Rehabilitation Program. 56. Taxes and Retroactive Financing. World Bank funds will be used to procure specified project inputs net of taxes. Retroactive financing of up to 10% of the Grant will be included for urgent purchases of project development and site preparation activities before project effectiveness, incurred after January 31, 1996. To advance delivery/completion further, advance contracting will be used to the maximum extent possible, subject to approval and effectiveness of financing. Environmental Aspects 57. The Project will follow accepted Bank procedures and as an emergency operation, the Project has not been assigned an environmental category. However, the Project is not expected to have any adverse environmental impact. All hospital-based and health center- based services will incorporate appropriate and safe disposal of wastes. Upgrading of prosthetic production facilities will ensure compliance with modern and safe waste disposal standards. Technical Annex Page 28 of 37 E. INSTITUTIONAL ARRANGEMENTS AND IMPLEMENTATION Project Organization 58. The Project will be implemented by the Federation MOH in close coordination and collaboration with the related health authorities at the national and local levels: cantons, municipalities, universities, NGOs, and other volunteer and donor agencies. To undertake its Health Reform and Reconstruction Program (para. 24), the MOH has proposed the establishment of a specific organization, including an Executive Office under the direct authority of the Minister and Deputy Minister, with two main responsibilities: (i) the design and implementation of the overall health sector recovery program, i.e., the five "pillars" described in para. 25; and (ii) the coordination of donor activities. 59. A Project Implementation Unit (PIU) will be established under the authority of the MOH Executive Office. The PIU will be responsible for: (i) day-to-day management, coordination and monitoring of project activities; and (ii) coordination of all other activities in physical and psycho-social rehabilitation being funded by other donor agencies in addition to those carried out through this Project. The Unit will be headed by a project director and will be supported in its work by two core groups: a full-time technical team and a part-time professional team. The technical team will be responsible for the more traditional implementation activities: civil works, procurement, accounting, etc. The professional team (comprised of members of the MOH working group which prepared the National War Victims Rehabilitation Program), will participate in implementation from the perspective of experts in physical and psycho-social rehabilitation, providing technical advice and expertise to the PIU. This type of support is important since MOH staff lack the skills and experience with the CBR approach adopted under the Project. This Professional Team will be employed on a part-time basis (estimated 1/3 time). Project Implementation Arrangements 60. Project activities will take place in selected health facilities throughout the country. On the basis of agreed criteria defined by the MOH/PIU (design and implementation plan finalized by the PIU Professional Team), local authorities will select the sites of the facilities, finalize equipment lists and recipient institutions, and agree on operational and administrative procedures. The PIU will provide assistance in these tasks. Since ownership, participation and commitment of the local health authorities are critical for the successful implementation of the Project, much attention will be given to this process. The objective will be to reach a "contractual agreement" between local authorities and the MOH, under which the local authorities commit to undertake the agreed activities, and the MOH (through the PIU) would provide the needed resources to implement the said activities. Such a "contractual agreement" does not constitute an on-lending instrument: all resources will remain under the control of the MOH/PIU that will make them available to local authorities according to the implementation schedule. The implementation arrangements for major activity areas are described below. Technical Annex Page 29 of 37 61. As soon as possible after Grant effectiveness, if not before, a Project Launch Workshop will be organized by the PIU. In addition to the authorities of the MOH and the PIU, this workshop will involve all responsible staff at the national, cantonal and municipal levels and responsible staff in the health facilities supported under the Project. The purpose of the workshop will be to: (i) review the project concept and activities; (ii) confirm the role and responsibilities of each level of authority and implementation; (iii) confirm and/or select the location of facilities to be supported under the Project in accordance with the agreed criteria; and (iv) finalize and agree on the implementation schedule. Within 30 days following the launch workshop, a procurement workshop involving all persons concerned with procurement, including the PIU, the Procurement Agent and the members of the Procurement Review Committee, will be organized by the PIU to review, explain and assign responsibilities for the procurement procedures set forth under the Project. Civil Works 62. Given the very limited implementation capacity of the MOH and the short duration of the Project, technical assistance from a civil works management firm will be needed by the PIU for: (i) assessing the needs for upgrading/remodelling of hospital departments, prosthesis production units and CBR centers; (ii) preparing civil works design and tender documents; (iii) carrying out tendering and selection procedures; and (iv) supervising civil works. It is proposed that this civil work management support be provided by the International Management Group (IMG) which is financed by the EU4. IMG has extensive prior experience in the required functions, and is currently organized and staffed in all parts of Bosnia and Herzegovina. The PIU (specifically, the PIU architect with the Professional Team) will be responsible for defining functional requirements and standards, for approving all documentation prepared by IMG, and for authorizing payments based on the reports and invoices received regularly from the contractors through IMG. Given the dispersed nature and small size of the packages of works (mainly renovation), civil works will be tendered through Simplified National Competitive Bidding (SNCB) (para. 81). Procurement of Goods and Supplies 63. The lists of equipment, materials, supplies, and furniture to be procured and their allocation to beneficiaries will be finalized by the PIU/MOH in consultation with the local health authorities, as part of the "contractual agreement". The procurement of equipment and medical supplies will be handled by a Procurement Agent (PA) to be contracted following a competitive process. Recruitment of the PA should be completed within 30 days following the establishment of the PIU. The PA will be responsible for: (i) preparing technical specifications and tender documents; (ii) carrying out tendering procedures and developing evaluation and selection criteria; and (iii) evaluating proposals on behalf of, and 41n the unlikely event that the European Union would not finance IMG for this Project, a civil work management firm would be selected on a competitive basis. Technical Annex Page 30 of 37 in coordination with, the PIU/MOH. The PA will also be responsible for inspecting the delivery and installation of the equipment, certifying payments in accordance with contract conditions and supervising the in-service training programs to be provided by the suppliers that will then be authorized by the PIU. To ensure that the procurement of works, goods and services is carried out in accordance with the procedures set for that purpose, a Procurement Review Committee will be established and will be responsible for the approval of final recommendations of contract award (ref. para. 82). 64. Considering the expected size of procurement packages, the medical equipment, pharmaceutical, medical materials and supplies will be procured through International Shopping (IS) (para. 77). Vehicles, furniture and office supplies will be procured through National Shopping (NS) (para. 78). Depending on the final size of the procurement packages, office equipment including PCs and printers, photocopy and fax machines will be procured either through IS or NS. Details of procurement packages are given in Appendix 5. Implementation of Community-Based Rehabilitation (CBR) Component 65. The CBR component will be implemented in the cantonal health facilities with the technical assistance provided by the PIU Professional Team and international assistance procured through the PIU. This international TA will be provided at two levels: (i) for the overall program design, development and management at the central level (PIU); and (ii) for operational and logistic support for the implementation of the on-site training at the local (facility) level. The criteria for the selection of the agency(ies) to provide technical assistance at the central and/or local levels will include skills and prior experience in: (a) the development and implementation of community-based strategies in the field of physical and psycho-social rehabilitation; (b) curriculum design; and (c) providing logistics for multifaceted projects to be implemented in several locations. 66. One of the first steps in the implementation of the CBR component is the organization of a series of workshops following the "contractual agreement" reached with the local health authorities. The purpose of the workshops, to be developed by the PIU/MOH with the support of the TA agency(ies), is to present the conceptual framework of the federal program and to assist in developing local implementation strategies and a detailed program for each canton. The local implementation programs will include: (i) the implementation schedule; (ii) the location of each CBR center; (iii) a staffing plan; and (iv) the lists of equipment to be procured for each CBR center. With the completion of each workshop, and once the various inputs will have been procured by the PIU, the local health authorities will be in a position to proceed with the implementation of the CBR program activities. 67. The on-site training under this component will begin with the establishment of the CBR centers by the local health authorities with support of the PIU/MOH. Technical assistance and logistic support will be provided at the local level in implementing on-site training programs. Technical assistance will include at least one trained occupational and Technical Annex Page 31 of 37 physical therapist working at each CBR for a period of six to eight weeks. Such assistance will be procured through short-listing (SL) or sole-sourcing (SS) where and when appropriate. 68. The development of an Occupational and Physiotherapy Program (OT/PT) will be supported through the Project. The University OT/PT program will be implemented by the Medical Faculties of Universities of Sarajevo, Tuzla and Mostar. Technical assistance (through the PIU at the central level), overseas training in rehabilitation for the educators specialized in occupational and physiotherapy, and limited equipment and learning resources will be provided under the Project for this purpose. Short-term overseas training programs for the educators of these Universities will be organized by the PIU with the support of the TA agency(ies). The technical assistance packages will be procured through short-listing (SL) procedures or sole-sourcing (SS) if justified. Considering the specificity of such services, training services will likely be procured through sole-sourcing. 69. The Public Education and Health Promotion activities will be contracted out to an organization, likely to be an association acting as a support group for disabled and very likely through sole-sourcing (SS). This organization will be supported by the (central) international technical assistance. This activity will include training and employment of war disabled persons in the production, management and marketing of promotional materials, with emphasis on disability prevention and health promotion. Implementation of Orthopedic and Reconstructive (O&R) Surgery Component 70. The activities under this component include: (i) rehabilitating facilities and providing essential equipment and medical supplies for the Orthopedic and Reconstructive Surgical units of seven selected hospitals (three Clinical Centers and four cantonal hospitals); and (ii) short-term overseas training for the staff of these units. The implementation arrangements for the civil works and procurement of equipment are described earlier (paras. 61-63). During each year of the Project, short-term overseas training will be provided for a group of two orthopedic surgeons, one anaesthetist and one theater nurse from each of the selected hospital facilities. Such overseas training will be procured through short-listing (SL) or sole- sourcing (SS) where and when appropriate. The teams will apply modern surgical, anesthesiological and postoperative/intensive-care techniques in their "home-hospital" upon their return. Implementation of Prostheses and Orthoses (P&O) Production Component 71. The activities under this component include: (i) rehabilitating facilities and providing essential equipment, raw material and supplies for the production of prostheses and orthoses to the selected P&O production and maintenance units; (ii) in-service training for the staff of these units; and (iii) establishment of a database unit in the MOH. The implementation arrangements for the civil works and procurement of equipment are described earlier (paras. Technical Annex Page 32 of 37 61-63). International technical assistance will be procured to provide in-service training programs which are to be implemented in these units. 72. Technical assistance will be provided for creating a standardized Federation-wide Data Base to collect and collate the information on amputees and disabled. Considering this standardization and the proprietary nature of the production equipment procured under the Project, such technical assistance may have to be procured through sole-sourcing (SS). All prostheses and orthoses production units and the corresponding hospitals will be provided with computers, each with printer and fax-modem and the suitable software. National technical assistance will also be provided for software training. All units included in the Project will provide monthly updates to the PIU/MOH. Project Implementation Schedule 73. The Project will be implemented over a two-year period. To allow for swift implementation of this emergency-type operation, procedures for project implementation will be kept simple. To secure the timely implementation of the Project, implementation schedules have been developed for each component (Appendix 6). Procurement Arrangements Procurement of Goods 74. The goods, including medical and essential equipment and supplies, office equipment and supplies, furniture, vehicles and learning resources will be procured using specified procedures. Pursuant to the decisions of the Bosnia Ad Hoc Advisory Committee and given the size of the procurement packages (Appendix 5) packages will be procured mainly through Limited International bidding (LIB), International Shopping (IS), National Shopping (NS) and Direct Contracting (DC). 75. Advertising. A General Procurement Notice (GPN, Appendix 7) will be published in the Development Business in May/June 1996. The notice will include information about the nature of the goods, works and services to be procured and invite interested and eligible suppliers, contractors and consultants to send their expression of interest to the PIU. The GPN will also be published in the local press. The GPN will be followed by specific advertisements for individual contracts in the local press. Bidding documents will be sent to suppliers who respond to the GPN and the specific advertisement. Expression of interest will also be used to prepare Limited International Bidding lists. 76. Limited International Bidding (LIB). LIB, tendering by invitation, will be used for procurement packages estimated to cost over US$2.0 million and up to US$5.0 million each. Exceptions to this threshold will be the cases where there will be only a limited number of suppliers. It is unlikely that LIB will be used at all under this Project. As Technical Annex Page 33 of 37 presented in Appendix 6, it is expected that all procurement packages will be under the US$2.0 million threshold, therefore being procured, through International or National Shopping (IS, NS) or Direct Contracting (DC) (see below). (a) List of LIB Bidders. The list of suppliers will be compiled based on the expressions of interest received in response to the General Procurement Notice as well as other sources, such as the Procurement Agent's own experience. The list will be as broad as possible. List of suppliers for LIB packages will be subject to the Bank's prior approval. (b) Bidding Documents for LIB. The Bank's Standard Bidding documents will be used. In order to expedite the process, LIB bidding documents will be sent by fax. 77. International Shopping (IS). Procedures for IS will be used for equipment and materials or standard specification commodities estimated to cost between US$200,000 and US$ 2.0 million per contract. IS will be based on comparing price quotations obtained from at least three suppliers from two eligible countries in accordance with Bank guidelines. 78. National Shopping (NS). NS will be used for contracts for goods available in Bosnia Herzegovina up to an estimated cost US$ 200,000 per contract with at least three quotations. 79. Direct Contracting (DC). DC will be used for proprietary items, for reasons of compatibility and standardization, and in any other justified case. Any direct contracting during project implementation will need prior Bank approval. 80. Recurrent Costs/Incremental Operating Costs. Recurrent Costs/Incremental Operating Costs will be procured as follows: PIU staffing will be procured under procurement procedures for consultants' services, and mostly on a sole source basis. Office supplies, pharmaceuticals, medical supplies, rental and other services will be procured through NS or IS, according to the availability of required items in Bosnia and Herzegovina, and the size of the procurement packages, and will follow the provisions set for NS and IS. Proprietary items such as gas and electricity will be procured through DC with local companies. Procurement of Works 81. Given the nature of the works, mainly rehabilitation of existing facilities, Simplified National Competitive Bidding (SNCB) will be used for contracts estimated to cost up to US$ 1.0 million per contract. These works will be procured under lump sum, fixed price contracts awarded on the basis of quotations obtained from three qualified contractors in response to a written invitation. The invitation shall include a detailed description of works, including basic specifications, the required completion period, a basic form of agreement acceptable to the Association and relevant drawings, where applicable. The award shall be Technical Annex Page 34 of 37 made to the contractor who offers the lowest price quotation for the required work and who has the experience and resources to successfully complete the contract. Procurement Review Committee 82. As stated above in para. 63, to ensure that the procurement of works, goods and services is carried out in accordance with the procedures set for that purpose, a Procurement Review Committee will be established and will be responsible for the approval of final recommendations of contract award. The Procurement Review Committee will be constituted of a representative from the MOH, a representative from the PIU and two representatives from the Clinical Centers and cantonal hospitals supported under the Project, and (for review of contracts other than for civil works) a member of IMG. The establishment of this Procurement Review Committee will be a condition of Grant effectiveness. Procurement of Services 83. Services will be procured through competition (short-listing) and sole-sourcing where and when appropriate. Qualified institutions and firms will be invited to submit proposals for comprehensive packages of consultant services and management of fellowships and training in accordance with the "Guidelines for the Use of Consultants by World Bank Borrowers and by The World Bank as Executing Agency" (August 1981). Local staff for the PIU will be procured through short-listing (SL) or, considering the fact that the Project should contribute strengthening of the MOH, through sole-sourcing (SS) of staff currently seconded to the MOH. To keep the evaluation process manageable, no more than six (but at least three) proposals will be invited following a short listing acceptable to the Bank. Prior and Post Bank Review of Procurement Documents 84. The Bank has prepared the invitation to quote and contract documents for International Shopping, Simplified Bidding documents for NCB and a National Shopping document for civil works. These documents would be used under the Project. Prior review will be required for all contracts procured through Limited International Bidding (LIB) and Direct Contracting (DC). Also, the first three contracts awarded through International Shopping (IS) and through UN Agencies, will require prior review from the Bank. For consultants' contracts, the Bank's standard form for consultants contracts will be used and prior review for consultants contracts conducted as required. Post review of procurement actions on a sample basis will be carried out during supervision missions. Technical Annex Page 35 of 37 Disbursements 85. Special Account. To facilitate timely project implementation, the State Ministry of Finance will establish under conditions acceptable to the Bank, a Special Account in US dollars in a commercial bank. The authorized allocation of the Special Account will be limited to US$1.0 million, representing about four months of estimated average expenditures expected to be paid from the Special Account. Replenishment applications will be forwarded to the Bank at least every three months and must include reconciled bank statements as well as other appropriate documents. For large contracts, such as medical equipment, the Bank will make direct payments to suppliers. 86. Statement of Expenditures. Disbursements will be made against Statements of Expenditures (SOEs) for contracts for goods and works up to US$1.0 million equivalent, except for the first three contracts procured under international shopping and through UN Agencies. Statements of Expenditures will also be allowed for expenditures for incremental operating costs, training, contracts with consultant's firms below US$100,000 and individuals below US$50,000. Disbursements for contracts exceeding US$3.0 million equivalent will be made against presentation to the Bank of full contract documentation. The Project completion date will be June 30, 1998. Accounts, Auditing and Reporting 87. Accounts. Separate and auditable accounts would be established with the PIU within MOH. These accounts would include: (i) a record of withdrawals with copies of all disbursement requests and underlying documentation; and (ii) a record of transactions on the special account and the copies of the bank statements on this account. 88. Audits. The project accounts will be audited annually by independent auditors and under terms and references acceptable to the Bank. Separate audit statements will be prepared for the Special Account and for Statements of Expenditures. All audit reports will be made available to the Bank, at the latest, six months after the end of the fiscal year. Project accounts will be maintained for one year after they have been audited. 89. Reporting. The PIU will prepare and furnish to the Bank a quarterly progress report showing the status of implementation of the Project as well as a financial report in a format acceptable to the Bank. The PIU will collect data from the Canton Administrations which will compile short quarterly progress reports. Supervision Plan 90. Project implementation will incorporate a large degree of flexibility in order to adapt to local implementation arrangements and rapidly changing circumstances in the country. Implementation progress will be formally evaluated at mid-term, i.e., approximately 12 months after effectiveness. In addition, during the first 6 to 12 months of Technical Annex Page 36 of 37 implementation, the Bank's Project Team (EC1/2HR staff in Budapest and Washington), jointly with the Social Sectors Operations Officer of the Bank's Resident Mission in Sarajevo, will continuously supervise all initial project implementation steps, and will assist closely on matters requiring advice and rapid decision by the Bank. In particular, procurement and disbursements will require intensive supervision, given the flexibility built into implementation. F. PROJECT BENEFITS, ECONOMIC JUSTIFICATION AND RISKS Project Benefits and Economic Justification 91. Benefits expected from the successful implementation of the Project fall into four categories. First, the Project will contribute significantly to reducing human suffering, an outcome that is impossible to quantify in and of itself. Beyond the numbers of physically disabled (the amputees and paraplegics, but also all those who have been injured and are left with some degree of disability) and of psychologically traumatized persons, there remains a lot of suffering that could significantly influence the vision and hopes for the future of the people of Bosnia and Herzegovina. Second, and related to the first point, the reduction of political instability is contingent upon the healing of the wounds associated with the war. On all sides, injuries and trauma have been caused by neighbors, relations or friends. Relevant therapy and care that the Project is intended to bring should facilitate progressive attainment of a reasonable degree of social and political reconciliation. These are pre-conditions for establishing a viable state. Finally, the Project constitutes the first opportunity given to the Bosnian health sector to develop cost-effective organization and functions. The strong emphasis on investments at the lower level of care (community-based) will pave the way for developing future activities clearly departing from the pre-war reliance on institutionalized care to a continuum of services anchored in the community. Moreover, through the establishment of a strong PIU, the Project should enable the Federation MOH to progressively resume its normal responsibilities in a rational way, enhancing its capacity for planning and implementing needs-based service delivery. 92. Economic Justification. On economic grounds, the Project will help reduce the lost productivity that would otherwise continue to result from the enormous burden of disease and disability due to physical and psycho-social trauma. By rehabilitating the victims of war, the Project will help meet a precondition for their re-integration into the economically active segment of society. The economic loss attributable to war inflicted physical disability and trauma is extremely difficult to measure. However, based on the 1990 prevalence of these conditions (intentional injuries and post traumatic stress disorders) and assuming that the conflict has considerably increased their incidence (three to five times), the loss of national production associated with the disabilities left untreated in the adult productive population (male and female ages 15 - 59), the segment of the population producing the national wealth, would range between 1 % and 2% of post-war GDP. Using 1.5 % and under the assumptions that: (i) employment opportunities are available; and (ii) the Project would result in the Technical Annex Page 37 of 37 restoration of 30% (a conservative assumption) of the lost ability to perform economic activities, it is estimated that the net annual gain in GDP would range between US$8.0 million and US$16.0 million. using a GDP per capita of US$500 or US$1.000. respectively. In any of these scenarios, this represents an unusually high return, fully justifying the investments planned under the Project. Project Risks 93. The main risk associated with the Project is that limited implementation capacity could delay its implementation. This risk will be mitigated through the setting up of a strong Project Implementation Unit supported by qualified technical assistance and reliance on professionals with the capacity for managing civil works and procurement. Turn-key contracts will be used where and when appropriate. Project implementation could also suffer from a shortage of co-financing. Active involvement of potential donors during project preparation and effective communication from the Government could help to secure the required co-financing. Finally, if the current low level of remuneration of health professionals and irregularity of payments is not addressed, there is a substantial risk of attrition of health professionals, especially the best qualified, and/or erosion of their commitment. This would have serious negative effects on the quality of health services delivered in general, and on the project-supported activities in particular. Additional donor financing could help alleviate this risk by temporarily complementing salaries of health professionals. Mechanisms to effectively allocate and manage these potential resources are being prepared. Sources of such financial assistance are yet to be identified. Appendix 1, Page 1 of 2 Appendix 1: The Status of Orthopedic and Reconstructive Surgical Units State Hospital, Sarajevo: Out of 420 previously available beds this hospital now has 250, 60 of which are for the traumatology/orthopedic department. It functions as a regional hospital. Out of a total of 7 operating theaters, one was destroyed during the war and 6 are in good condition, and 2 of these belong to the traumatology/orthopedic department. These 2 require minor repairs. One intensive care unit was destroyed as well, but there is another one with 20 beds, out of which 10 are allocated to the surgical departments. Some minor repairs and replacement of broken glasses are required. University Clinical Center Kosevo. Sarajevo: Out of more than 4,000 beds before the war, the University Clinic now has 1,850. Apart from the traumatology/orthopedic department there are 12 other surgical departments. To meet the demands of the large influx of the war wounded, it was necessary to reorganize the health care system in the clinical center. Orthopedics and traumatology became one combined department in the same building with 5 theaters. Of these 5 theaters, 4 are in good condition and one needs replacement of the floor covering. Some in-patient rooms need new windows. The intensive care unit is in good condition. The access road from the entrance of the Clinical Center compound to the clinic of traumatology/orthopedics is in very poor condition and unsuitable for seriously injured patients. Tuzla Hospital: According to the MOH, this hospital shall be the location of the second medical faculty of the Federation. The traumatology/orthopedic department has 120 beds. Zenica Hospital: This was one of the larger cantonal hospitals with tertiary-level services. During the war it was developed through the help of the Danish government into a big 1,200-bed rehabilitation clinic of high standard in which 40 to 50 beds are allocated to the orthopedic department. Mostar Hospital: This is a huge concrete building erected just before the outbreak of the war, with almost all civil works already done. Assessments of the extent of damage due to the war, the repairs needed and resources required for its completion need to be done by a civil engineer. Mostar, according to the MOH, shall become the third major center of university level health care in the Federation. The orthopedic/traumatology department has a capacity of about 75 beds, located in temporary premises. Livno Hospital: Located between Mostar and Bihac, this small cantonal hospital offers tertiary-level services in its department of traumatology and orthopedics which has 30 to 40 beds. Bihac Hospital: This is also a cantonal hospital, with a 40-bed orthopedic/ traumatology department. Appendix 1, Page 2 of 2 Orthopedic and Reconstructive Surgical Units in Bosnia-Herzegovina, February, 1996 Hospital Rehabilitation Department Community Based Rehabilitation Clinic CBR Sarajevo Kosevo * Yes 5 CBR Clinics: Dobrinja, State Hospital * Yes Alipasino Poije, Novo Sarajevo, Praxis, Neretva plus 2 prosthetics units pp Tuzla * p Yes: Polyclinic, plus 1 CBR: Srebrenica Rehabilitation Institute/Center for spinal cord injuries l Zenica * p Yes, plus Rehabilitation 1 CBR: Nemila Institute Mostar * _p Yes 1 CBR rLivno * No Bihac * p No Gorazde (war hospital, No future uncertain) ** Travnik ** Yes Jajce (destroyed in the war) * Orthopedic surgery ** General surgery p Prosthetics unit Appendix 2, Page 1 of 3 Appendix 2: The Status of Prostheses Production and Maintenance Units Central Prosthetics and Rehabilitation Unit in Sarajevo (Neretva). This unit was expected to take substantial responsibilities for program design, monitoring and implementation of the physical rehabilitation programs in the Sarajevo area, while the regional centers would be created to implement the assistance to war victims in their respective zones of activity. Allocation of the program resources from the center to the periphery was supposed to be linked to regional plans of action. Neretva is currently not in a position to fulfil these responsibilities. There are urgent needs for major changes in this institution: Work Methods: The work process needs altering, notably the present arrangement whereby up to six persons are involved in the making of one prosthesis. This means that no one can take full responsibility in the rehabilitating process of a particular patient and the patient has no direct "partner" in this important part of the physical rehabilitation process. There is therefore an urgent need for training and introduction of modern production techniques. It will be important to appoint also an expatriate workshop manager who has the skills needed for applying modern methods and for training others (minimum duration of assignment, 3 months). Capacity Building: A major reduction of the existing personnel and concurrent recruitment of enthusiastic young technicians should be the next step in the process of achieving increased productivity. In-service management training through external technical assistance should be a priority. The expatriate and his/her local counterpart could coordinate the Federation-wide prosthetic and rehabilitation plan. As managers they should be situated in Neretva, and as coordinators they should be attached to the Ministry of Health to coordinate the implementation of the plan. Supplies: For some time Neretva produced no prostheses because it had run out of raw materials. Finally it received supplies in 1995 but still lacks other materials and sufficient equipment to become the center for the whole Federation. Civil Works: The Neretva workshops are still in two different buildings. The major production unit is on the hill in church premisses where it occupies about 1700 m2. The major rehabilitation unit is still in the Neretva owned building in the center of the town (on a plot of about 800 m2) but major parts of the infrastructure are completely destroyed. For this a complete reconstruction would be less expensive than rehabilitation and/or repairs of the existing buildings. A new construction would also enable the construction of a 3-floor building to accommodate Neretva again, with approximately 2,500 M2 in total. For the time being it is planned that Neretva will move soon to a building behind (and belonging to) the State Hospital. Appendix 2, Page 2 of 3 Center for the Production of Orthopedic Appliances. The small workshop in the center of Sarajevo is run under the umbrella of the local NGO "Merhamet". The workshop was equipped through funds from different national Caritas organizations through CRS. The difference between the workshop of e.g. Neretva and this small unit is striking as one finds here the most recent Otto Bock machines, rawlings and all other needed supplies for one year, tools and physical rehabilitation equipment in renovated small building. Even more impressive are the prostheses they fabricate. The two technicians produce prostheses of high technical and aesthetic quality. This workshop could provide some competition for Neretva, and it could be developed into the national center for upper limb prostheses, of which there is none in the country. In-service training of about 3 months in the initial phase and refresher courses would be required. No investments are required for civil works. Tuzla Workshop. This workshop, which is managed by Handicap International, produces only temporary prostheses for the initial phase after operation. As there are not enough facilities for permanent prostheses the amputees use their temporary prostheses often too long (several months, up to even 3 years). The fitting of a permanent prosthesis after such a long time is very difficult and often reamputation is required. There are urgent needs to "upgrade" this workshop into a unit which can produce good prosthesis as described above. New machines, tools, equipment and operational supplies for at least 2 years will be as needed, as well as training for the technicians. Major investments in civil works are not expected as it would be wise to use the existing premisses of handicap international. Zenica Workshop. This is an excellent workshop with very good equipment for 5 technicians. By the end of 1995, it had registered 944 patients, out of which 83 % had lower limb amputations of different kinds. 379 of these prostheses are finished (40%). Unfortunately the workshop "lost" all their skilled technicians which resulted in serious degradation of the quality of work. In addition, the most recent rawlings delivered were of poor quality, and the prostheses do not meet the required standard. They have to be replaced after 3 to 4 years, whereas a good prosthesis should last at least 6 and can last up to 10 years. Minor repairs are required in the workshop, some equipment have to be replaced, others added. There are urgent needs for supplies, consumables and very urgent in-service training, which should be carried out together with the delivery and installation of the new equipment. Foinica. Fojnica is the site of the large national rehabilitation center. Some responsible people in the Ministry of Health as well as the management of Neretva wanted very much to establish a branch of Neretva near to the clinic to serve the patients of the center, which should then become enlarged up to 700 beds capacity. In the context of the now agreed community based approach it would be much more reasonable to do the opposite, reducing the capacity of the rehabilitation center and putting more emphasis into the community based structures (see below). Appendix 2, Page 3 of 3 Mostar. The unfinished building requires civil work investments for completion. It also requires equipment to become operational. Currently there is only a small service workshop, without major equipment, proper tools, consumables and supplies. In-service training for at least 3 month would be required. Bihac. Although Bihac was chosen already in the beginning of 1995 to be a administrative as well as medical, orthopedic and traumatology/ reconstructive surgery center, the new prosthetic workshop was just recently set up in Cazin, 26 km north of Bihac. The German NGO "Johanniter Unfallhilfe" has equipped the small unit with Otto Bock equipment and all necessary supplies which should last up to the end of the year. There are no costs for civil works expected. Supplies should be planned for a period of about 2 years, training will be as essential as for the other units. Livno. Livno has no facilities at all for prosthesis production or servicing. The decision to set up completely new workshop, including infrastructure, equipment and supplies should be postponed until the final data from the planned screening are available. It might be appropriate regarding future sustainability and self financing requirements to make Livno a very small prosthesis servicing center. This small workshop could be accommodated in the existing premisses of the hospital and much less equipment and supplies would be needed. The technician could be trained together with colleagues in Cazin or in Mostar. Appendix 3: Organization of Rehabilitation Services Prostheses &- Hospitals: Hospitals: Orthoses: Physical Rehabilitation Psycho-Social -Production "*'0_ -Orthopedic & Reconstructive surgery Rehabilitation -Maintenance -Short-Stay Rehabilitation -Acute Care Psychiatry Orthoses: -Chronic Psychoses Community-B3ased Physical PyCommunity-Based Rehability-ation Phscl Psycho-Social Rehabilitation Rehabilitation -Medication -Ohsccptoal Therapy -Individual Psychotherapy -Occupational Therapy -Group Therapy -Counselling -Counselling -Occupational Therapy -Home Visits Homes ~Homes Homes Homes COST ESTIMATES Appendix 4 Page 1 of 8 Coat Summary by Project Components (USS 000) CBR Prosthesis Orthopedic Project Expenditure Category Program Units Surgical Implementation TOTAL % INVESTMENT COSTS CIVIL WORKS 2,670.00 955.00 1,300.00 115.00 5,040.00 16.8 EQUIPMENT AND MATERIALS 3,278.44 3,096.50 4,400.00 22.50 10,797.44 36.0 Essential Equipment 2,056.44 695.00 4,400.00 7,151.44 Prothesis and Raw Materials 2,331.00 2,331.00 Office Equipment 906.00 70.50 22.50 999.00 Learning Resources 316.00 316.00 FURNITURE 420.00 0.00 0.00 20.00 440.00 1.5 VEHICLES 0.00 75.00 175.00 18.00 268.00 0.9 TECHNICAL ASSISTANCE 1,536.00 480.00 0.00 1,473.22 3,489.22 11.6 Intemational 1,200.00 480.00 252.00 1,932.00 Local 36.00 1,221.22 1,257.22 Education & Promotion 300.00 300.00 TRAINING 180.00 52.00 504.00 45.00 781.00 2.6 Overseas Training 90.00 504.00 22.50 616.50 Local Training 90.00 52.00 22.50 164.50 Total Investment Costs 9,084.44 4,658.50 6,379.00 1,693.72 20,375.66 67.9 RECURRENT COSTS Operational Costs 2,100.00 140.00 48.00 2,288.00 Supply and materials 2,436.00 1,231.00 2,100.00 72.00 5,839.00 Total Recurrent Costs 4,536.00 1,371.00 2,100.00 120.00 8,127.00 27.1 TOTAL BASE COST 12,620.44 6,029.50 8,479.00 1,813.72 28,942.66 CONTINGENCIES 485.41 219.09 306.37 59.01 1,069.88 3.6 TOTAL COST 13,105.85 6,248.59 8,785.37 1,872.73 30,012.54 100.0 _ % 43.7 20.8 29.3 6.2 100.0 COST ESTIMATES Appendix 4 Page 2 of 8 ESTIMATES AND DISBURSEMENT SCH Prosthesis Disbursement Schedule Component FY96 FY97 FY97 FY98 FY98 TOTAL Component________________ IQ4 Q1/2 Q3/4 Q1/2 Q3 Community-Based Rehabilitation Amount 0.917 3.275 6.288 1.965 0.655 13.1 Percent 7% 25% 48% 15% 5% 100% Prostheses and Orthoses Production Amount 0.31 3.1 1.24 0.93 0.62 6.2 Percent 5% 50% 20% 15% 10% 100% Orthopedic and Reconstructive Surgery Amount 0.44 2.64 4.136 1.32 0.264 8.8 Percent 5% 30% 47% 15% 3% 100% Project Implementation Support Amount 0.285 0.532 0.475 0.475 0.133 1.9 Percent 15% 28% 25% 25% 7% 100% Total Amount 1.952 9.547 12.139 4.69 1.672 30.0 Percent 7% 32% 40% 16% 6% 100% COST ESTIMATES Appendix 4 Page 3 of 8 Component: Orthopedic&Reconstructive (O&R) Surg Prosthesis Unit Total Physical Expenditure Category Unit Quantity Cost Base Cost Contingency TOTAL INVESTMENT COSTS CIVIL WORKS Rehabilitation of 3 O&R clinics lump sum 750.00 52.50 802.50 Rehabilitation of 4 cantonal O&R units lumpsum 550.00 38.50 588.50 Subtotal Civil Works lump sum 1300.00 91.00 1391.00 ESSENTIAL EQUIPMENT lump sum For 3 O&R clinics lump sum 2800.00 84.00 2884.00 For 4 cantonal O&R units lump sum 1600.00 48.00 1648.00 Subtotal Equipment 4400.00 132.00 4532.00 VEHICLES Wheelchair accessible minivans piece 7 25.00 175.00 5.25 180.25 Subtotal Vehicles 175.00 5.25 180.25 TRAINING Overseas Training/ i m/m 168 3.00 504.00 15.12 519.12 Subtotal Training 504.00 15.12 519.12 Total Investment Costs 6379.00 243.37 6622.37 RECURRENT COSTS Surgical supplies for O&R units per unit 7 300.00 2100.00 63.00 2163.00 Total Recurrent Costs 2100.00 63.00 2163.00 TOTAL COST 8479.00 306.37 8785.37 notes 1/ short-term training for 2 surgeons, 1 anesthesist and 1 theatre nurse per unit for 3 months (first and second year) COST ESTIMATES Appendix 4 Page 4 of 8 Component: Prostheses and Orthoses (P&O) Production Cost Summary (US$ 000) Prosthesis Unit Total Physical Expenditure Category Unit Quantity Cost Base Cost Contingency TOTAL INVESTMENT COSTS CIVIL WORKS Central P&O Prod unit in Sarejevo per unit 1 650.00 650.00 45.50 695.50 Regional P&O Production units / I per unit 2 90.00 180.00 12.6 192.60 maintenance centers per unit 5 25.00 125.00 8.75 133.75 Subtotal Civil Works per unit 955.00 66.85 1021.85 EQUIPNENT AND MATERIALS per unit Essential Production Equipment per unit 695.00 20.85 715.85 Central P&O Prod unit in Sarejevo per unit 1 175.00 175.00 5.25 180.25 Regional P&O Production units per unit 2 85.00 170.00 5.10 175.10 maintenance centers per unit 5 70.00 350.00 10.50 360.50 Protheses and Production Materials per unit 2331.00 69.93 2400.93 Central P&O Prod unit in Sarejevo per unit 1 1800.00 1800.00 54.00 1854.00 Regional P&O Production units per unit 2 178.00 356.00 10.68 366.68 maintenance centers per unit 5 35.00 175.00 5.25 180.25 Office Equipment 70.50 2.12 72.62 PC,faxmodem, printer/ 2 piece 15 4.50 67.50 2.025 69.53 photocopymachine piece 1 3.00 3.00 0.09 3.09 Subtotal Equipment and Materials 3096.50 92.90 3189.40 VEHICLES Wheel accesible minivans / 3 piece 3 25.00 75.00 2.25 77.25 Subtotal Vehicles 75.00 2.25 77.25 TECHNICAL ASSISTANCE International 450.00 13.50 463.50 In-service trainer /4 n/rm 30 15.00 450.00 13.5 463.50 Local 30.00 0.9 30.90 Software trainer mWm 12 2.50 30.00 0.9 30.90 Subtotal TA 480.00 14.40 494.40 TRAINING Local training / 5 lump sum 52.00 1.56 53.56 Subtotal Training 52.00 1.56 53.56 Total Investment Costs 4658.50 177.96 4836.46 RECURRENT COSTS Operational Costs 140.00 4.20 144.20 Central P&O Prod unit in Sarejevo per unit 1 75.00 75.00 2.25 77.25 Regional P&O Production units per unit 2 20.00 40.00 1.20 41.20 maintenance centers per unit 5 5.00 25.00 0.75 25.75 Supply and materials 1231.00 36.93 1267.93 Central P&O Prod. unit in Sarejevo per unit 1 700.00 700.00 21.00 721.00 Regional P&O Production units per unit 2 178.00 356.00 10.68 366.68 maintenance centers per unit 5 35.00 175.00 5.25 180.25 Total Recurrent Costs 1371.00 41.13 1412.13 TOTAL COST 6029.50 219.09 6248.59 notes: I/ In Tuzla, Mostar. 2/ One for each P&O Production and maintenance unit, and 7 for MOH. 3/ One for each P&O Production unit. 4/ 3 months for each P&O Production and maintenance units and 6 month for upperlimb production techniques. 5/ During the first year; 6 workshops for for each P&O Production unit for 15 persons and for 5 days in the second year refresher training; 2 workshops for 15 persons for 5 days. COST ESTIMATES Appendix 4 Page 5 of 8 Subcomponent: Community-Based Physical Rehabilitation Cost Summary (US$ 000) Unit Total Physical Expenditure Category Unit Prosthesis Cost Base Cost contingency TOTAL INVESTMENT COSTS CIVIL WORKS Physical CBR centers per unit 22 45.00 990.00 69.3 1059.30 Hospital Dep. ofPhysicalRehab. per unit 8 15.00 120.00 8.40 128.40 Subtotal Civil Works per unit 1,110.00 77.70 1,187.70 EQUIPMENT AND MATERIALS per unit Essential Equipment per unit 1591.44 47.74 1639.18 Physical CBR per unit 1385.00 41.55 1426.55 Equipmentfor CBR physicians per unit 30 2.50 75.00 2.25 77.25 OT&PTEquipment per unit 22 45.00 990.00 29.70 1019.70 Hospital Dep. ofPhysicalRehab. per unit 8 40.00 320.00 9.60 329.60 OT/PT Equipment/i per unit 3 68.81 206.44 6.19 212.63 Office Equipment 201.00 6.03 207.03 Physical CBR centers piece 22 7.50 165.00 4.95 169.95 Hospital Dep. ofPhysicalRehab. piece 8 4.50 36.00 1.08 37.08 Leaming Resources 196.00 5.88 201.88 Physical CBR centers per unit 30 4.00 120.00 3.6 123.60 OTIPT program per unit 3 25.33 76.00 2.28 78.28 Subtotal Equipment and materials 1988.44 69.66 2048.09 FURNITURE Physical CBRs per unit 30 8.00 240.00 7.20 247.20 0TTIPT program/I per unit 2 7.50 15.00 0.45 15.45 Subtotal Furniture 266.00 7.65 262.66 TECHNICAL ASSISTANCE Intemational 750.00 22.50 772.50 OTIPTprogram developmentl 2 m/m 20 15.00 300.00 9.00 309.00 CBR Specialistsfor onsite training /3 n/m n30 15.00 450.00 13.50 463.50 Local 18.00 0.54 18.54 Translator m1rm 18 1.00 18.00 0.54 18.54 Health Promotion Study per unit 300.00 9.00 309.00 Subtotal TA 1,068.00 32.04 1,100.04 TRAINING Overseas Training /4 per unit 12 7.50 90.00 2.70 92.70 Local Training /5 per unit 450 0.10 45.00 1.35 46.35 Subtotal Training 135.00 4.06 139.06 Total Investment Costs per unit 4656.44 181.09 4737.63 RECURRENT COSTS Operational Cost &Transportation 1140.00 34.20 1174.20 Physical CBR centers per unit 30 38.00 1140.00 34.2 1174.20 Notes: 1494.00 44.82 1538.82 1/ Fulltime trainers for 12 months 1350.00 40.50 1390.50 2/ 3 workshopsfor 50 personsfor 3 days per unit 30 30.00 900.00 27 927.00 Medical Supplies per unit 30 7.00 210.00 6.3 216.30 Consumables and office supplies per unit 30 8.00 240.00 7.2 247.20 Hospital Physical Rehab. Dept. 144.00 4.32 148.32 Pharmaceuticals per unit 8 18.00 144.00 4.32 148.32 Total Recurrent Costs 2634.00 79.02 2713.02 TOTAL BASE COST 7190.44 260.11 7450.66 Notes: 1/ For Universities of Tuzla, Sarajevo and Mostar. 2/ 5 specialists for 4 months for curriculum and learning resomrces developmnent 3/ Full-time trainers for 12 montas. 4/ 4 faculty staff from each university for 3 months. 5/ 3 workshops for 50 persons for 3 days. COST ESTIMATES Appendix 4 Page 6 of 8 Subcomponent: Community Based Pscyho-social Rehabilitation Cost Summary (US$ 000) Unit Total Physical Expenditure Category Unit Prosthesis Cost Base Cost contingency TOTAL INVESTMENT COSTS CIVIL WORKS Psycho-social CBR centers per unit 30 45.00 1350.00 94.50 1444.50 HospitalDep.ofPsycho-socialRehab. per unit 14 15.00 210.00 14.70 224.70 Subtotal Civil Works 1560.00 109.20 1669.20 EQUIPMENT AND MATERIALS Essential Equipment 465.00 13.95 478.95 Rehabilitation equipmentfor CBR centers per unit 30 8.50 255.00 7.65 262.65 Hospitals&Dep.ofPsycho-socialRehab per unit 14 15.00 210.00 6.30 216.30 Office Equipment 705.00 21.15 726.15 Psycho-social CBR centers per unit 30 20.00 600.00 18.00 618.00 Hospital Dep.of Psycho-social Rehab. per unit 14 7.50 105.00 3.15 108.15 Learning Resources 120.00 3.60 123.60 Psycho-social CBR centers per unit 30 4.00 120.00 3.60 123.60 Subtotal Equipment and materials 1290.00 38.70 1328.70 FURNITURE Psycho-social CBRs per unit 30 5.50 165.00 4.95 169.95 Subtotal Furniture 165.00 4.95 169.95 TECHNICAL ASSISTANCE International 450.00 13.50 463.50 CBR Specialists for onsite training/I m/m 30 15.00 450.00 13.50 463.50 Local 18.00 0.54 18.54 Translator r/rm 18 1.00 18.00 0.54 18.54 Subtotal TA 468.00 14.04 482.04 TRAINING Local Training /2 m/day 450 0.10 45.00 1.35 46.35 Subtotal Training 45.00 1.35 46.35 Total Investment Costs 3528.00 168.24 3696.24 RECURRENT COSTS Operational Cost &Transportation per unit 30 32.00 960.00 28.8 988.80 Medical Supply and Consumables 942.00 28.26 970.26 Psycho-social CBR centers 690.00 20.70 710.70 pharmaceuticals per unit 30 18.00 540.00 16.2 556.20 Consumables and office supplies per unit 30 5.00 150.00 4.5 154.50 Hospital Psycho-social Rehab. Dept. 252.00 7.56 259.56 Pharmaceuticals per unit 14 18.00 252.00 7.56 259.56 Total Recurrent Costs 1902.00 57.06 1959.06 TOTAL BASE COST 5430.00 225.30 5655.30 Notes: 1/ Fulltime trainers for 12 months. 2/ 3 workshops for 50 persons for 3 days. COST ESTIMATES Appendix 4 Page9, 7d Component: CBR Program Cost Summay (UJSS 000) Unit Total Physical Expenditure Category Unit Prosthasu Cost Base Cost contigrency TOTAL INVESTMENT COSTS CIVIL WORKS Physical CBR 1,110 00 77.70 1,187.70 PhysalCBR centerR per unit 22 45.00 990.00 693 1059.30 HospitalDep of PhysicalRehab. per unit 8 15.00 120.00 8.40 128.40 Psycho-social CBR 1580.00 109.20 1869.20 Psycho-social CBR cenhers peru-i1 30 45.00 135000 94.50 1444.50 Hospil.lDepofPsycho-socialRehab. per wii 14 1500 210.00 14.70 224.70 Subtotal Civil Works 2670.00 186.90 2856.90 EQUIPMENT AND MATERIALS Essential Equipment 2056.44 61.69 2118.13 Physical CBR 1385.00 41.55 1428.55 Equ ip.enfor CBRphysicians perunit 30 2.50 75.00 2.25 77.25 OT&PTEquip.ent per unit 22 45.00 990.00 29.70 1019.70 Hospital Dep. ofPhysscalRehab. perunit 8 40.00 320.00 9.60 329 60 Psycho-social CBR 465.00 13.95 478.95 Reho.bihiatio equipment per unit 30 8.50 255.00 7.85 262.65 Hjsospnoh&Dep.ofPsyrho-.oia/Rehab paruni 14 1500 210.00 630 216.30 OT/PTEquipment/i p -unit 3 68.81 206.44 6.19 212.63 Office Equipment 908.00 27.18 93318 Physical CBR 201.00 6.03 207.03 Physical CBR centers piece 22 7.50 165.00 4.95 169.95 HospitalDep. of PhysicalRehab. piece 8 4.50 36.00 1.08 37.08 Psycho-social CBR 705.00 21.15 72615 Psycho-socialCRRcente,r per unit 30 20.00 600.00 18.00 618.00 l1ospiiolDep.ofPsycho-.ocialRehab. per unit 14 7.50 105.00 3.15 108.15 Leaming Resources 316.00 9.48 325.48 Physial CAR en ers per unil 30 4.00 120.00 3.6 123.60 Psycho-social CAR centers per unit 30 4.00 120.00 3 60 123.60 OT/PTprogra- per unit 2 38.00 76.00 2.28 78.28 Subtotal Equipment and materials 3278.44 98.35 3376.79 FURNITURE PhysicalCBRR peru-it 30 8.00 24000 72 247.20 Psycho-social CBRs perunit 30 5.50 165.00 4.95 16995 7T/PT pro,raf/l per unit 2 7.50 15.00 0.45 15.45 Subtotal Furniture 420.00 12.60 432.60 TECHNICAL ASSISTANCE International 1,200.00 36.00 1,236.00 OTPT program development/ 2 mW/ 20 15.00 300.00 9.00 309.00 CBR Specialistfor onsite raining /I m/m 60 15.00 900.00 27.00 927.00 Local 36 00 1.08 37.08 Translator m/m 36 1.00 36.00 1.08 3708 Health Promotion Study lump sum 300.00 9.00 309.00 Subtotal TA 1,536.00 46.06 1,582.08 TRAINING OverseasTrainuig /4 m/m 12 7.50 90.00 2.70 92.70 Local Training /s r/day 900 0.10 9000 2.70 92.70 Subtotal Training 180.00 5.40 185.40 Total Inveatinent Costs ODS4.44 349.33 S433.77 RECURRENT COSTS Operational Cost &Transportation 2100.00 83.00 2183.00 Physical CBR centers per unit 30 38.00 1140.00 34.2 1174.20 Psycho-social CAR cent ers pwmit 30 32.00 28.8 988.80 Medical Supply and Consumables 2436.00 73.08 2509.08 Physical CBR centers 1350.00 40.50 1390.50 Phmnaceuticale per unit 30 30.00 900.00 27 927.00 MedicalSupplies perunit 30 7.00 210.00 6.3 216.30 Consumables and office upplies per unit 30 8.00 240.00 72 24720 Hospital Physical Rehab. Dept. 144.00 4.32 148.32 Pharmaceuticale per unit 8 18.00 144.00 4.32 148.32 Psycho-social CBR centers 890.00 20.70 710.70 pharmaceuticalt per unit 30 18.00 540.00 16.2 556.20 Consumables and office spplies per unlt 30 5.00 150.00 4 5 154.50 Hospital Psycho-social Rehab. Dept. 252.00 7.58 259.56 Pharraaeutlcat per unit 14 18.00 252.00 7.56 259.56 Total lecurrent Cosb 4536.00 136.06 4672.08 TOTAL BASE COST 12620.44 485A1 13105.85 notes: U For UnUversities ofTuzJa. Sarajevo and Mostar. 2/ 5 specialists for 4 months for cuiciulumn and leaming resources developmnt. 3/ 5 fuDtume trainrs for 12 nionths. 4v 4 faculty staff from each university for 3 months. 5/ 6 workshops for 50 persons for 3 days. COST ESTIMATES Appendx 4 Page 8 of 8 Component: Project Implementation Support Cost Summary (USS 000) Prosthesis Unit Total Physical Expenditure Category Unit Quantity Cost Base Cost contingency TOTAL 11VESTMENT COSTS CIVIL WORKS Office Renovation lump sum 115.00 8.05 123.05 Subtotal Civil Works 115.00 8.05 123.05 EQUIPMENT Office Equipment PC,fax modem andprinter piece 4 4.50 18.00 0.54 18.54 communication(fax+telephone) piece 1 1.50 1.50 0.05 1.55 photocopy machine piece 1 3.00 3.00 0.09 3.09 Subtotal Equipment 22.50 0.68 23.18 FURNITURE lump sum 20.00 0.60 20.60 Subtotal Furniture 20.00 0.60 20.60 VEHICLES car piece 1 18.00 18.00 0.54 18.54 Subtotal Vehicles 18.00 0.54 18.54 TECHNICAL ASSISTANCE International 252.00 7.56 259.56 Civil Works Management Services lump sum 252.00 7.56 259.56 Local 1,221.22 36.64 1,257.86 Procurement Services lump sum 867.22 26.02 893.24 project director n/M 24 2.50 60.00 1.80 61.80 architect n/im 9 2.00 18.00 0.54 18.54 procurement specialist m/m 24 2.00 48.00 1.44 49.44 accountant m/m 24 1.50 36.00 1.08 37.08 support staff m/m 72 1.00 72.00 2.16 74.16 technical experts/I n/M 40 3.00 120.00 3.60 123.60 Subtotal TA 1,473.22 44.20 1,517.42 5. TRAINING Overseas Training / 2 m/m 3 7.50 22.50 0.68 23.18 Local /3 days 225 0.10 22.50 0.68 23.18 Subtotal Training 45.00 1.35 46.35 Total Investment Costs 1,693.72 55.41 1,749.13 RECURRENT COSTS Operational cost per month 24 2.00 48.00 1.44 49.44 Office supplies and materials per month 24 3.00 72.00 2.16 74.16 Total Recurrent Costs 120.00 3.60 123.60 TOTAL COST 1,813.72 59.01 1,872.73 notes: 1/ 5 experts (working group members) on part-time basis. 2/ Study tours for 6 persons for 2 weeks. 3/ 3 workshops for 15 persons for 5 days. Appendix 5 Page I of 3 Bosnia and Herzegovina War Victims Rehabilitation Project Proposed Procurement Arrangements (US$ million ) Procurement Methods Project Element IS" SNCB' NSA' DCO OTHER TOTAL 1. WORKS5' 1.1 Rehabilitation of CBR centers 2.86 2.86 (2.00) (2.00) 1.2 Rehabilitation of O&R clinics 1.39 1.39 (0.75) (0.75) 1.3 Rehabilitation of P&O production 1.02 1.02 units and maintenance units (0.65) (0.65) 1.4 PIU office renovation 0.12 0.12 (0.12) (0.12) Subtotal 5.39 5.39 (3.52) (3.52) 2. GOODS 2.1 OT/PT Equipment for Physical 1.64 1.64 CBR centers hospital departments (0.90) (0.90) and Universities 2.2 Equipment for Psycho-social CBR 0.48 0.48 centers and hospital departments (0.20) (0.20) 2.3 Equipment for O&R clinics and 4.53 4.53 unitsO (0.75) (0.75) 2.4 Essential Production Equipment 0.72 0.72 for P&O and maintenance units (0.20) (0.20) 2.5 Protheses and raw Materials for 2.40 2.40 P&O and maintenance units7' (0.40) (0.40) 2.6 Office Equipment 1.03 1.03 (0.47) (0.47) 2.7 Learning Resources 0.33 0.33 (0.15) (0.15) 2.8 Fumiture 0.45 0.45 (0.17) (0.17) 2.9 Vehicles' 0.28 0.28 Subtotal 11.08 0.45 0.33 11.86 (2.92) (0.17) (0.15) (3.24) 3. TECHNICAL ASSISTANCE9' 3.59 3.59 (0.92) (0.92) 4. TRAINING SERVICES'0' 0.80 0.80 (0.80) (0.80) 5 RECURRENT COST 5.1 Operating Cost"' 2.36 2.36 (0.40) (0.40) 5.2 Supply and Materials'2' 6.01 6.01 (1.12) (1.12) TOTAL PROJECT COST 11.08 5.39 0.45 0.33 12.76 30.01 (2.92) (3.52) (0.17) (0.15) (3.24) (10.00) * Numbers may not add to total because of rounding. * Figures in parentheses represent the World Bank contribution through the TFBH Grant and IDA Credit Appendix 5 Page 2 of 3 Notes: 1/ International Shopping. 2/ Simplified National Competitive Bidding. 3/ National Shopping. 4/ Direct Contracting. 5/ To be procured under several packages by canton and/or unit. 6/ To be procured under several packages according to the type of the equipment and instruments. 7/ To be procured under two packages for first and seond year. 8/ To be procured under two packages according to the type of vehicle. 9/ Technical assistance services consist of both TA packages and individual consultants. TA packages would be procured either through LIB or DC where and when justified. The services of individual consultants would be engaged through comparison of two or three CVs or Direct Contracting in case of a lack of more than one qualified candidate. 10/ Local training services will be engaged through NS or DC in case of lack of qualified local service providers overseas training services will be engaged through IS or DC where and when justified. 11/ Operating cost including expenditures for heating, electricity, transportation, etc. will be reimbursed based on statements of expenditures. 12/ Supplies and materials will be purchased through NS or IS depending on the availability of local suppliers and the value of the package. Appendix 5 Page 3 of 3 Bosnia and Herzegovina War Victims Rehabilitation Project Project Procurement Plan Component Total Cost Likely Invitation to Bid Contract Award Work/Delivery All Work/Delivery US$ million Procurement Begins Complete Methods Rehabilitation of CBR Centers 2.00 SNCB 5/96 6/96 6-7/96 10-12/96 Rehabilitation of 0 & R Clinics 0.75 SNCB 5-6/96 6-7/96 6-7/96 11-12/96 Rehabilitation of P & 0 Units 0.65 SNCB 5-6/96 7/96 6-7/96 11/96 PIU Office Renovation 0.12 SNCB 5/96 5-6/96 6/96 9/96 OT/PT Equipment 0.90 IS 5-6/96 7/96 10/96 12/96-3/97 Equipment for Psycho-Social 0.20 Is 5-6/96 7/96 10/96 12/96-3/97 CBR Equipment for 0 & R Units 0.75 IS 7/96 8-9/96 11/96 12/96-3/97 Production Equipment for P & 0 0.20 IS 7/96 8-9/96 11/96 12/96-3/97 Units Prostheses and Raw Materials 0.40 IS 7/96-7/97 8196-8/97 11/96 12/96-12/97 for P & 0 Units Office Equipment 0.47 IS 5-6/96 7/96 10/96 12/96-3197 Learning Resources 0.15 DC --- 10/96-3/97 12/96 6/97 Furniture 0.17 LS 5/96 8/96 10/96 3/97 Technical Assistance: 0.92 LIB/DC 6-10/96 8-12/96 8/96 6/98 TA for PIU 0.35 DC -- 5/96 5/96 6/98 TA for Program Devt. for 0.49 LIB/DC 5/96 7/96 8/96 6/97 P&O Units TA for Health 0.08 DC 9/96 10/96 11/96 5/97 Training Services 0.80 IS/DC 6-10/96 8-12/96 8/96 6/98 Recurrent Expenditures 1.52 IS/LS 5/96 6/96-3198 6/96 6/98 (Supplies. Materials, Operational Expenditures) PROJECT IMPLEMENTATION SCHEDULE Appendix 6 Page 1 of 7 Component | Activity i Start Date |End Date |Responsibility Project Implementation Support Establishment of PIU Minister of Health to appoint PIU director and staff, assign office space, authorize PIU budget, establish project accounts and records 15-May-96 MOH Develop Cantonal Develop National Implementation Implementation Strategies and Program I-Mar-96 30-Mar-96 MOH Programs Organize series of workshops to introduce and discuss National Implementation Program and Strategy and to develop PIU/MOH Cantonal Implementation Programs I-May-96 20-May-96 CHA Make 'contractual agreements" with PIU/MOH CHAs to define responsibilities 22-May-96 30-May-96 CHA Engage IMG to undertake Develop TOR for the management of management of civil civil works 15-May-96 25-May-96 PIU/MOH works Make contract with the IMG 30-May-96 PIU/MOH Contract out Prepare TOR, receive and evaluate procurement services proposals and contract award 15-May-96 15-Jul-96 PIU/MOH CHA: Cantonal Health Authorities; IMG: International Management Group; MOH: Ministry of Health; PA: Procurement Agency; PIU: Project Implementation Unit PROJECT IMPLEMENTATION SCHEDULE Appendix 6 Page 2 of 7 Component |Activity IStart Date |End Date |Responsibility CBR Program Rehabilite CBR Select site for each CBR centers facilities standards 22-May-96 30-May-96 CHA Determine functional requirements and standards 10-May-96 27-May-96 PIU Determine rehabilitation needs for each CBR center 25-May-96 11-Jun-96 IMG/CHA Prepare technical specifications and evaluation criteria, select firms, send invitation to bid, obtain approval of MOH and no objection from the Bank 1-Jun-96 15-Jul-96 IMG/PIU Award contract 16-Jul-96 20-Jul-96 PIUIMOH Renovate CBR centers 24-Jul-96 10-Sep-96 contractors Supervise rehabilitation works make progress payments to contractors 24-Jul-96 10-Sep-96 IMG/PIU Procure equipment Finalize lists of equipment and supplies to be and supplies for CBRs procured for each CBR center 15-May-96 30-May-96 PIU/CHA Prepare technical specifications & evaluation criteria, select firms, send invitation to bid, obtain approval of MOH and no objection from the Bank 20-May-96 8-Jun-96 PA/PIU Carry out IS procedures 10-Jun-96 29-Jun-96 PA/PIU Obtain no objection from the Bank and award contract 1-Jul-96 5-Jul-96 PIU/MOH Delivery and installation 5-Sep-96 15-Oct-96 PA/suppliers/CHA CHA: Cantonal Health Authorities; IMG: International Management Group; MOH: Ministry of Health; PA: Procurement Agency; PIU: Project Implementation Unit PROJECT IMPLEMENTATION SCHEDULE Appendix 6 Page 3 of 7 Component Activity Start Date End Date Responsibility Select TA agency(ies) Prepare TOR, and determine shortlist of firm/agencies, send RFP, receive and evaluate proposals, obtain approval of the MOH and no objection from the Bank 6-May-96 26-Jun-96 PIU Award contract 27-Jun-96 6-Jul-96 PIU/MOH On-site training program Develop training program and learning resources for CB physical and psycho-social TA agency/ rehabilitation programs 8-Jul-96 30-Sep-96 PIU/CHA Deliver on-site training programs I-Oct-96 5-Jul-97 TA agency/ PIU/CHA OT/PT program support Develop OT/PT curriculum and short-term overseas training program for faculty staff 8-Jul-96 30-Oct-96 TA agency/PlU/ Select faculty staff to go abroad, select training institutions and make necessary arrangements I-Aug-96 15-Sep-96 faculties/PIU Short-term overseas training I-Oct-96 25-Dec-96 TA agency/PIU/ -training institutions CHA: Cantonal Health Authorities; IMG: International Management Group; MOH: Ministry of Health; PA: Procurement Agency; PIU: Project Implementation Unit PROJECT IMPLEMENTATION SCHEDULE Appendix 6 Page 4 of 7 Component |Activity I Start Date |End Date |Responsibility Prostheses and Orthoses (P&O) Production Rehabilitation of P&O Determine facilities to be rehabilitated 22-Apr-96 30-Apr-96 MOH/CHA Production & maintenance Determine functional requirements and units standards 10-Apr-96 27-Apr-96 PIU Determine rehabilitation needs for each unit 25-Apr-96 I -May-96 IMG/CHA Prepare technical specifications and evaluation criteria, select firms, send invitation to bid, obtain approval of MOH and no objection from the Bank 10-May-96 30-Jun-96 IMG/PIU Award contract 1-Jul-96 5-Jul-96 PIU/MOH Renovate facilities 6-Jul-96 30-Aug-96 contractors Supervise rehabilitation works make progress payments to contractors 6-Jul-96 30-Aug-96 IMG/PIU CHA: Cantonal Health Authorities; IMG: International Management Group; MOH: Ministry of Health; PA: Procurement Agency; PIm: Project Implementation Unit PROJECT IMPLEMENTATION SCHEDULE Appendix 6 Page 5 of 7 Component Activity Start Date End Date Responsibility Procure equipment Finalize lists of equipment and supplies to be and supplies for P&O procured for each unit 20-Apr-96 5-May-96 PIU/CHA units Prepare technical specifications and evaluation criteria, select firms, send invitation to bid, obtain approval of MOH and no objection from the Bank 10-May-96 1-Jun-96 PA/PIU Carry out IS procedures 5-Jun-96 5-Aug-96 PA/PlU Obtain no objection from the Bank and award contract 6-Aug-96 10-Aug-96 PIU/MOH Delivery and installation 15-Sep-96 30-Sep-96 PA/suppliers/CHA Carry out IS procedures for the second lot of raw materials and supplies I-Mar-97 15-Apr-97 PA/PIU Obtain no objection from the Bank and award contract 16-Apr-97 25-Apr-97 PIU/MOH Delivery and installation I-Jun-97 15-Aug-97 PA/suppliers/CHA Select TA agency(ies) Prepare TOR, and determine short-list to develop and deliver of firm/agencies, send RFP, receive in-service training program and evaluate proposals, obtain approval of the MOH and no objection from the Bank 15-May-96 12-Jul-96 PIU Award contract 15-Jul-96 20-Jul-96 PIU/MOH Develop and deliver Develop training program and learning TA agency/ in-service training program resources I-Aug-96 30-Sep-96 PIU/CHA Deliver in-service training programs I-Oct-96 30-Jun-97 TA agency/ PIU/CHA CHA: Cantonal Health Authorities; IMG: International Management Group; MOH: Ministry of Health; PA: Procurement Agency; PIU: Project Implementation Unit PROJECT IMPLEMENTATION SCHEDULE Appendix 6 Page 6 of 7 Component |Activity IStart Date |End Date |Responsibility Orthopedic and Reconstructive (O&R) Surgery Rehabilitation of O&R Determine facilities to be rehabilitated 22-Apr-96 30-Apr-96 MOH/CHA units Determine functional requirements and standards 10-Apr-96 27-Apr-96 PIU Determine rehabilitation needs for each unit 25-Apr-96 11-May-96 IMG/CHA Prepare technical specifications and evaluation criteria, select firms, send invitation to bid, obtain approval of MOH and no objection from the Bank I-May-96 15-Jun-96 IMG/PIU Award contract 16-Jun-96 20-Jun-96 PIU/MOH Renovate facilities 24-Jun-96 10-Aug-96 contractors Supervise rehabilitation works make progress payments to contractors 24-Jun-96 10-Aug-96 IMG/PIU Procure equipment Finalize lists of equipment and supplies to be and supplies for O&R units procured for each unit 15-Apr-96 30-Apr-96 PIU/CHA Prepare technical specifications and evaluation criteria, select firms, send invitation to bid, obtain approval of MOH and no objection from the Bank 20-May-96 8-Jun-96 PA/PIU Carry out IS procedures 10-Jun-96 29-Jun-96 PA/PIU Obtain no objection from the Bank and award contract I-Aug-96 10-Aug-96 PIU/MOH Delivery and installation 15-Sep-96 15-Oct-96 PA/suppliers/CHA CHA: Cantonal Health Authorities; 1MG: International Management Group; MOH: Ministry of Health; PA: Procurement Agency; PIU: Project Implementation Unit PROJECT IMPLEMENTATION SCHEDULE Appendix 6 Page 7 of 7 Component Activity Start Date End Date Responsibility Short-term overseas training Select O&R staff to go abroad select training institutions and make necessary arrangements 1-Aug-96 15-Sep-96 faculties/PIm Short-term overseas training 1-Oct-96 25-Dec-96 PIU/hospitals/ 1 -Mar-97 31-May-97 training institutions CHA: Cantonal Health Authorities; IMG: International Management Group; MOH: Ministry of Health; PA: Procurement Agency; PIU: Project Implementation Unit Appendix 7, Page 1 of 1 Bosnia and Herzegovina War Victims Rehabilitation Project GENERAL PROCUREMENT NOTICE The Government of Bosnia and Herzegovina is expected to receive a credit from the World Bank Trust Fund established for supporting the emergency reconstruction program for the country. The proceeds of the credit would be used for a proposed War Victims Rehabilitation Project. The Government is also expected to receive loans and grants from other multilateral sources, such as the European Union, and from several bilateral sources. The loans and grants mentioned above are intended to be used for emergency recovery of the health system in Bosnia and Herzegovina. It is intended that the loans and grants would finance the cost of the following procurement: 1. Import of medical equipment, spare parts, supplies, pharmaceuticals and vehicles for physical and psycho-social rehabilitation centers, rehabilitation and mental health hospital departments, and orthopedic and reconstructive surgery hospital departments 2. Import of production equipment, materials and supplies for prostheses and orthoses production and maintenance units. 3. Import of office equipment, furniture, supplies and pedagogical materials. 4. Consultant services (community-based rehabilitation specialists, occupational/physical therapy specialists, prostheses/orthoses production in- service trainers) Given the emergency nature of the project, the above mentioned goods and consultant services will be procured through accelerated procurement procedures within the framework of the procurement guidelines and regulations of the World Bank, European Union, and other possible participating financing agencies and donors. Interested suppliers and manufactures and consulting firms are invited to send their expression of interest to the address specified below. As eligibility requirements of the World Bank, the European Union and other financing agencies and donors vary for participation in bidding, the Purchaser will prepare a list of interested suppliers, manufacturers and consulting firms according to their eligibility. As and when the Purchaser will be ready with bidding documents or with invitations to quote, these will be sent to those who will respond to this notice. Name: Dr. Bozo Ljubic Minister of Health Address: Ministry of Health Alipasina 41, Sarajevo 7100 Bosnia and Herzegovina Phone: +387 71 618 735 Fax: +387 71 618 735 Sumn)ary of Technical Specifications Appendix 8 Page 1 of 3 Prostheses and Orthoses Production Units List of most urgent needs for the production of orthopaedic and orthotic appliances item/material quantity specification I Working table for taking measure I piece 2 Sterilisator 1 3 Screen I1 4 Bed I 5 Water basin for POP 4 6 Electrical hand tools for mechanic 1 set 7 Workbench for lamination 1 piece 8 Workbench for prosthetic I 9 Vice for lamination I 11 Vacuum apparatus 1 12 Electronic scale 1 13 Socket rooter 1 14 Belt sander I 15 Band saw 1 16 Fixed/standing vertical drilling machine 1 17 Different hand tools for prostheses I set 18 Cupboard for tools 5 pieces 19 Cupboard for materials 5 20 Heater 1 21 Chairs 12 22 Sewing machine for leather 1 23 Mill/rooter I 24 Vice for mechanic and bandagist 3 25 Tuming-lathe 1 26 Electrical welding apparatus 1 27 Different hand tools for bandagist I set 28 Iron sheet cutter 1 piece 29 Combined finisher and trimmer I 1 30 Different hand tools for shoemaker I set 31 Anvil for shoemaker 1 piece 32 Cupboard for models 1 " 33 Officefumiture 1 set Summary of Technical Specifications Appendix 8 Page 2 of 3 List of essential equipment for the orthopedic and reconstructive surgical units number of hospitals which need this number of 'items" No. item "item" needed per hospital 1. Instruments Instruments for 7 hospitals 7 1 "set" Additional instr. for 3 hospitals 3 1 "set" 2. Sterilisation 4 1 "set" 3. Mobile x-ray with TV 5 1 'set' 4. Theatre equipment Mobile furniture 7 1 "set" Orthopedic theatre table 2 1 High frequency app. for el. surg. 7 1 Monitoring system for theatre 7 1 Compressor for air 4 1 Electrical theatre aspirator 7 1 5. Anesthesia equipment Anestesia apparatus 7 1 Mobile resucitation-unit 7 1 Perfusor 7 3 Pump for syringes 7 2 6. Intensive care unit equipment Monitors for postoperative care unit 7 2 Summary of Technical Specifications Appendix 8 Page 3 of 3 List of Instruments for orthopedic and reconstructive surgery units No. item / container with units needed 1 Basic instruments 1 2 Supplement bones I 3 Bending instruments 1 4 Supplement amputation 1 5 Supplement (AO) screw-up set 1 6 Supplement minifragment 1 7 Flexible pipe support 1 8 Supplement shoulder 1 9 Drilling machine (AO) I 10 Mini drilling machine 1 12 Hand set 1 13 Scalpels 2 14 Clamp set 2 15 Supplement for tendons 1 16 Chisels I 17 Supplement for cerclage I 18 Set of keys 1 19 Supplement for removal of implants 1 20 "Emergency vessel" set 1 21 Reserve instruments 1 22 DHS & DCS instruments 1 23 Skingrafting (meschgraft) set 1 24 Unreamed nail set tibia 1 25 Unreamed nail set femur 1 26 Instruments for POP 1 27 Fixateur externe, "SARAFIX" 4 Appendix 9 List of Supporting Volumes and Documents in Project File Academy of Sciences and Arts of Bosnia and Herzegovina. Psycho-Social Aspects of The War in The Republic of Bosnia and Herzegovina. Special Publications Volume CII. Sarajevo, 1995. Federation Health Program. Health Reform and Reconstruction Program of the Federation of Bosnia and Herzegovina. Ministry of Health. January, 1996. International Center for Migration and Health. Reproductive Health and Pregnancy Outcomes Among Displaced Women. Report of the Technical Working Group. October, 1995. Office of the United Nations Special Coordinator for Sarajevo. Plan for the restoration of essential public services in Saraievo: Health Working Group Action Plan. Prepared by the WHO in consultation with the Ministry of Health, Bosnia-Herzegovina and other national and international organizations. July, 1994. Preker, A., Feachem, R. Health and Health Care. In Barr, N. (Ed.). Labor Markets and Social Policy in Central and Southern Europe. Oxford University Press. New York. 1994. UNICEF. Draft situation analysis. Office of the Special Representative, UNICEF Emergency Operations in Former Yugoslavia. October, 1993. World Health Organization. WHO contribution to Special Coordinator for Saraievo Report. July, 1995. World Bank. World Development Report 1993. Investing in Health. Oxford University Press. New York. 1993. MAP SECTION IBRD 27716 kTr TaZogreb 18 To Osijek To Zagreb To Zagreb C R 0 A T I A To Vinkovci To Osijeks , --.NaToGIino - lin CROATIA Novi ,) To Belgrade Kn-, r g nsh 4 2Cozin 0 ( r.o - .0 Bi Pao ILEER < < ti C H-+CTLA N znc 5 0 KiuE <100 ZEH> OLND URAN RIVERS 500 z / GER AANY\ --. - , P z > 69 NATIOaNAL CAPITAL 10_ \,1jJ a HUMNGAY / 42C -T - INTERNATIONAL BOUNDARIES T_ - 0 LEDk PE R_ ITALY Bw5scSLvA ULGARIA ovo-~~~~nciSovu A41~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~A 40 L'c ziceALNtA-- 40' lo° 17O 18° 10° 20Y TURKEY U TOURY19 IMAGING Report No:- 6841 BIH Type: MOP