World Bank Document · 2016. 7. 17. · Consultant), Dubravka Kulisic (Economist, and David Nuin (InfonnationTrrechinology Manager, Consultant). John Catford (Public Health Advisor,

Document of

The World Bank

Report No. 13717-HR

STAFF APPRAISAL REPORT

REPUBLIC OF CROATIA

HEALTH PROJECT

JANUARY 26, 1995

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

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CURRENCY EOUIVALENT

Currency Unit - Croatian Kunas (KN)(Kunas replaced Dinar in June 1994)

AVERAGE EXCHANGE RATES(Croatian Kunas per US$)

June 1994 US$1.00 = KN 6.07July 1994 US$1.00 = KN 5.80

September 994 US$1.00 = KN 5.85

WEIGHTS AND MEASURESMetric System

FISCAL YEARJanuary I - Deceinber 3 1

ABBREVIATIONS AND ACRONYMS

CIF Cost Insurance FreightEBRD European Bank for Reconstruction and DevelopimentGDP Gross Domestic ProduCtGP General Practiti(onrrsHI] Health Insurance InstituteIBRD International Bank tor Reconstruction andl DevelopmentICB International Comrpetitive BiddingICU Intensive Care UnitIDA Internati(onal Development AgencyIMF International Monetary FundIS International ShoppingLS Local ShoppingMOF Ministry of FinanceMOH Ministry of HealthNIPH National Institute of Publihc HealthPHC Primary Health CarePIO Project Imnplementation OftficerPPF Project Preparation FacilityPIP Project Implementation PlanSOE Statement of ExpendlitureUNPA UJnited Nations Protected AreaWHO World Health Organization

REPUBLIC OF CROATIA

HEALTH PROJECT

STAFF APPRAISAL REPORT

Table of Contents

Page No.

Loan and Project Summary ............................................ i

I. INTRODUCTION ............................................. IA. Country/Sector Background ................................... IB. The Government's Reform Strategy .............................. 2C. Rationale tor Bank Involvement ................................ 4

II. THE PROJECT.. 4A. Project Objectives and CoGmponents. 4B. Project Description. 5C. Environmental Impact. 8

III. PROJECT COSTS. FINANCING, MANAGEMENT AND IMPLEMENTATION ... 8A. Introduction ............................................. 8B. Project Cost ............................................ 8C. Project Financing ................... ..................... 9D. Administration of Project Funds ................................ 9E. Project Management and Implementation ............... ........... 9F. Project Procurement Arrangements .............................. 10G. Dishursements .......................................... 10H. Project Audit Reporting and Evaluation .......................... 111. Status of Preparation ...................................... I I

IV. BENEFITS AND RISKS I........................................ 11

V. AGREEMENTS REACHED AND RECOMMENDATION .................. 12

ANNEX I Project Implementation Plan ... 13

MAP: IBRD-26529

This report is hased on the findings of a mission which visited Croatia in Septeinher, 1994. The mission was comprised ofWin. Bradford Herbert (Mission Leader, Senior Operations Officer, ECI/2HR), Teresa J. Ho (Senior Health Economist(EC2HU), Virginia H. Jackson (Operations Officer, ECI/2HR), Craig R. Neal (Infornation System Specialist (EMTDR),Mathias Kalina (Acute Care Specialist, Consultant), Aynur Kadihasanoglu (Planning and Implementation Specialist,Consultant), Dubravka Kulisic (Economist, Consultant), and David Nuin (InfonnationTrrechinology Manager, Consultant). JohnCatford (Public Health Advisor, WHO) also participated in the mission. Edith Santos (EC 1/2HR) provided assistance with textprocessing. Task Manager: Win. Bradford Herhert (ECI/2HR); Division Chief: Ralph W. Harhison (ECI/2HR) and AndrewRogerson, Manager (EC2HU); Director: Keinal Dervis (EC2DR); Peer Reviewers: Philip Musgrovc (PHN). and SaliimHabayeb (SA2PH).

REPUBLIC OF CROATIA

HEALTH PROJECT

Loan and Project Summary

BORROWER: Republic of Croatia

BENEFICIARIES: Ministry of Health (MOH), Health Insurance Institute (HII), primary healthcare centers, and selected hospitals.

LOAN AMOUNT: US$40.0 million equivalent

TERMS: Seventeen years, including a five-year grace period, at the IBRD standardvariable interest rate.

PROJECTOBJECTIVE: The primary goal of the Health Project is to support and sustain the

Government's health care retform program as set forth in the 1993 CountryHealth Development Program. To achieve this goal, the specific objectives ofthe Project are to: (a) improve the operational and financial managementsystem of the Health Insurance Institute by supporting the computerization ofinformation systems; (b) improve the quality of the health care deliverysystem by providing laboratory and diagnostic equipment for primary healthcare facilities. and basic equipment ancl training for hospitals and emergencyservices; and (c) improve the health status of the population by supportinghealth promotion programs.

PROJECTDESCRIPTION: The proposed Project will provide financing for computer hardware and

software, medical equipment, fellowships, study tours, foreign and localtraining and expert advisory services, public education materials, andincremental recurrent costs. The estimated total cost of the Project isUS$54.0 million, of which US$40.0 million will be financed by the Bankloan. The Project will be implemented over a period of four years by HI]under the supervision and guidance of MOH. and will consist of threecomponents:

Health Insurance Administration (estimated base cost US$13.9 million). Thiscomponent will improve health insurance administration by developing theinformation technology network linking central, district and branch offices ofthe HII, and by introducing "credit card" style health insurance identificationwards.

Primary Care and Health Promotion Services (estimated base cost US$14.9million). This component will improve the quality and availability of basicdiagnostic services for the primary care network through the provision ofstandard diagnostic equipment (standard and specialized x-rays. and simplelaboratories), as well as the required training for medical, nursing and

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parameldical personnel. This component will also intensify programs topromote healthier lifestyles among the population through the training andsupport of Comilmunity health promotion teams, primary car-e providers, andschool teachers, and through mass media eutication programins.

Essential Hospital and Emergency Services (estimated base cost US$ 19.3million). This comrponent will upligade essential acute care services thmiughthe provision of hasic equipiment tor the emergency medlical system, intensivecare units, and perinatal care units in selectedl hospitals. as well as relate(dtraining for mendical. nursing, and paramnedical personnel.

BENEFITS: Health promotion activities, together with increased early screening forchronic disease, will contribute in the long run to im-proved health and to aredLICtion in premature mo )rtality particiIlarl y trolm card liovascUlaI disease andcancer. Primary care and essential hospital andl emergency equipment willimnprove the qiuality andL acceptahility of care, as well as the "value tC mrmoney" of services andL will make a substantial contribihti m to health g ainsthroLigh a reduction in mortality andL mo0rhidity fromi1 acdCidedntS acute medicalemergencies. and perinatal corpiplications. Cost-effectiveness will also beincreased by shifting part of meidical care from the secondary andL tertiarylevels to the primary level. Improvements in health insulance administrationwill facilitate financial control and permit the effects ot financial controls onhealth outcomes to he monitored. Tangible imprpovements in care willstrengthen the credihility of the on-going reform efforts. Specific targets areshown in Annex I of the Statff Appraisal Report

RISKS: The Project itselt'does not fiace many project-specitic risks. 'I'he ret'olillpolicy for the health sector is heing im-plementedl by a teamii which comiimiandsrespect on all sides of the political spectirum1l Preparation for i mplementationand procurement is far advanced, which should lead to goodl disbursementperformance. The main risk remains, unfortunately, a CoLinty r isk steminingfrom the uniesolvedi status of the zones ciurrently not contiolled by theCroatian Government. This situation creates ongoinT tensioll which coulderupt in reniewel hostilities, and would no dotubt (lelay the successfulimrplementation of this Pro'ject. While most observers considel the risk ofmajor hostilities on Croatian territory to he small, it is not insignificant. Onthe other hand, the Croatian authorities have relpeatedly committed themselvesto a negotiated settlement, and over the last two years. have shown greatinterest and willingness to coolperate with the interinatioail comlmlllinity. Theyhave also honored all their ohligations to the Bretton-W ods institutionls andhave embarked on an active piograin ot cooperation with the IMF, the IBRDandl the EBRD which has already made two im)portant loans, paralleling ourown efforts. The substantial economic gains achieved through the stahilizationand re'forimi prograin are in fact strengthening the long-term rprospects for alasting peace.

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Estimated Costs and Financing Plan'

Local Foreign Total(llS$ Million)

1. Health Insurance Adlministration 8.2 5.7 13.92. Primary Health Care Services 5.3 9.6 14.93. Essential Hospital Services 3.7 15.6 19.3

TOTAL BASE COSTS 17.2 30.9 48.1

Physical Contingencies 0.8 2.9 3.7Price Contingencies 1.0 1.2 2.2

TOTAL PROJECT COSTS; 19.0 35.0 54.0

Financina Plan:

Health Insurance Institute 14.0 0.0 14.0IBRD 5.0 35.0 40.0

TOTAL 19.0 35.0 54.0

Including taxes and duties equivalent to US$0.8 million. Most imported items linanced by internationalagreements are exeinlpt froni duties and Ltxes. Detailed numbers may not add iti totals due It rounding.

REPUBLIC OF CROATIA

HEALTH PROJECT

STAFF APPRAISAL REPORT

1. INTRODUCTION

A. Country/Sector Background!'

1.1 After its first democratic elections in 1990, Croatia started reorganizing a healthsystem that was fragmented and inefficient. Adult mortality was high, especially among males, andwas dominated by lifestyle-related, non-communicable disease (especially cardiovascular and cancer).In 1991, Croatia's population was 4.8 million with a per capita income of US$2,442. Lifeexpectancies were 67 and 75.5 years for men and women, respectively. The main causes of deathwere circulatory diseases (55 percent), neoplasms (22 percent). and injury and poisoning (15 percent).The infant mortality rate was 12.8 per 1,000 live births in 1993. While there was wide access toprimary care and preventive programs, the content of primary care was greatly restricted (limitedmainly to referral services and elementary prescription), and public health services were dedicatedmainly to "traditional" tasks such as hygiene and sanitation rather than to the prevention of non-communicable disease. The system was inefficient, and overly-reliant on hospital services, with nobuilt-in incentives for cost control. By 1990, the health sector had accumulated debts of US$210million, which represented about 1 .3 percent of GDP (Gross Domestic Product) and one-quarter ofannual sector expenditures. As a result of shortages in investment funds, the stock of equipment andinfrastructure had deteriorated to a point where some older radiological equipment was reportedlydangerous for staff and patients (more than 80 percent of radiology ecluipment is over 20 years old).

1.2 By late 1990. the health sector was in a state of crisis. Government revenues forhealth were lagging far behind expenditures. costs were rapidly escalating, and there were no systemsin place for effective management. The Government of Croatia and the Ministry of Health (MOH)recognized that the existing system was no longer sustainable and made the decision to reform thesector. In early 1991, they initiated a reform built around: (a) a reduction in the role of the state:(b) a more efficient allocation of responsibility between central and local governments; (c) aredefinition of basic health services and improvement in the quality of these services: and (d) arevamping of health financing.

1.3 The outbreak of war in 1991 interrupted reform efforts and had a major impact on thehealth system. An increase in the demand for health services as a result of war injuries as well as theinflux of displaced persons from the areas in Croatia not currently under Government control UnitedNations Protected Areas (UNPAs) and from Bosnia and Herzegovina have put an enormous strain onthe system. This is especially true for the transitory population/displaced persons in the area ofemergency services and primary heaith care. Nonetheless, the Government's stated policy to provideprimary health care and acute care to all registered refugees is hy and large being carried out. At thesame time, destruction of infrastructure, equipment. and emergency vehicles in areas affected by warhas decreased the supply of health services. Budgets for health also deCreased: real expenditures in

1/ Additional sector background infonnation cian be founld in the woirking paper "Croatia Social Sectors and SocialExpenditures Review", August 1994, prepared by ECI/2HR

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1993 were 37 percent lower than in 1991 and accounted for 6 percent of GDP (down from7.6 percent in 1991). Per capita health expenditures decreased from US$393 in 1991 to US$148 in1993. Although there has been an overall decrease in real expenditures, Croatia's expenditure inhealth (as a percentage of GDP) remains one of the highest among Eastern European countries. Thissuggests that the challenge facing Croatia is one of cost containment and "value for money" ratherthan increasing expenditures in the sector.

B. The Government's Reform Strategy

1.4 The Government's reform strategy had two immediate objectives: (a) to end thechronic financial deficit; and (b) to increase the efficiency of health services by moving from an over-reliance on curative and secondary clinical care to primary and preventive care. To meet theseobjectives, the Government took tough decisions and followed up with actions that few countries havebeen willing to undertake. The reform called for instituting fiscal discipline, and for reducing wasteand improving management through the introeduction of incentives and revamping the financingsystem.

1.5 To carry out the retfrm program, the Government passed two important laws inAugust 1993. The Health Care Act estahlished primary care as the foundation of the system,transferred ownership of most health facilities from the central authorities to district governments,defined a management structure for all health institutions (including a Management B1oard withrepresentation from the local government, the Health Insurance Institute (Hll), health practitioners,and a Chief Executive Officer who reports to the Management Board), authorized private practice,and mandated the MOH to define a national network of health institutions that would be eligible forfinancing under the health insurance system. The Health Insurance Act established the Hll withconsiderable authority to enforce collection of contributions, negotiate and sign contracts with healthproviders, and supervise and financially control business transactions of health facilities and privatepractitioners.2 The Act also added mandatory contributions from the Pension Fund to the payroll-based revenues of the Health Fund, currently set at 15 percent." Finally, the Act allows for theestablishment of voluntary insurance schemes to supplement comnpulsory insurance. Together, thesetwo acts have instilled the discipline essential to the success of the Government's reform strategy inthe health sector.

1.6 The initial implementation of reforms has been highly successful. Since passage ofthe Health Care Act, the MOH has defined standards for coverage for primary care services as wellas acute, highly specialized and chronic care beds, taking into consideration the current financialcapability within the system. Regional maps of epiidemiological status have been prepared on the

2/ Prior to this act thc hc alth insu ra nce systcim was admi in istercd by i hc Repo hic Fund( to r Health Insunrance . ThisFund lacked the legislative authority, political support, and administrative strnietoire to bc effective.

3/ Payroll-hased health contributions conisist of 7.5 percent f'rom the einploycr and 7.5 pcrcent fromlic h employce.Including the contributions for social security, labor market, and children's fund, total payroll taxes amount to47.3 percent of net wages. Although this figure is lower thani most Eastern European countries, the labordisincentive and informtal econoimy enhancing efl'ects of high payroll taxation suggest this to tal in Croatia shouldnot be allowed to increase. Other sources of revciutic to the Health Fund come from pensioners and a smallamount from the State budget whicih covers special categorics of the population.

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basis of which health insurance contracts have been drawn up. Through its legal authority, the HIlhas established a point system with "caps" on overall expenditures for reimbursing hospital costs and

a capitation system for primary care physicians. Other measures to control costs, including limits on

the number of prescriptions and of referrals, have also been introduced and are closely monitored.

These measures, combined with strenuous efforts to collect unpaid contributions, have nearly

eliminated Health Fund deficits. A program of debt negotiations, including partial write-offs, debt-

equity swaps and subsidized payments from the national budget, has resulted in a reduction in health

sector debts from US$210 million in 1990 to US$8.9 million in mid-1994.

1.7 The early success of financial reform can be attributed to a number of factors. There

is strong commitment from the Government, Parliament, and the MOH bureaucracy. which has been

translated into action. The HIT has been mandated to take tough decisions and to instill discipline in

the system.-' Health facilities and providers are aware of the consequences if they do not reduce

costs and "balance the books". Introduction of the right incentives has made a difference. For

example, the point system favors lower-cost interventions at secondary levels, and General

Practitioners (GPs) can receive a bonus if the number of referrals is kept below the upper limit. The

result has been to intro(luce rational decision-making based on efficiency and cost-effectiveness into

the system.

1.8 The MOH is also turning its attention to the system's longer-term sustainability byreorienting the service package towards more cost-effective primary care and health promotion

services. The centerpiece of its Primary Healthi Care (PHC) Strategy is the privatization of the PHC'

network, a task which it hopes to accomiplish over a period of five years. The MOH is preparing an

Act on the Privatization of Primary Care which, among other things, would allow private

practitioners to lease facilities from the pLublic sector and establish individuals' rights to choose their

physicians with an opportunity to change once a year. MOH's strategy also includes increasingaccess to diagnostic services to help GPs expand the scope and quality of services offered. The

ultimate objective is to meet 70-80 percent of health needs at the primary care level (this ratio is

currently at 25-40 percent). The Health Promotion Program. which is an essential element of value

for money, has also been revived recently. The MOH successfully persuadecd Parliament to pass a tax

increase on alcohol and cigarettes. Warnings on the dangers of smoking are now required on all

cigarette packaging, and smoking is bannedl from public buildings. Social marketing techniques are

also being developed to acidress lifestyle factors an(d high-risk behaviors contr-ibuting to chronic

disease and premature mortality among acdults.

1.9 While the MOH is rightftully pleased with its accompllishmiients in financialmanagement, it recognizes that fiscal discipline can only he maintained by efficient ftunctioning of the

health insurance system andl continuous monitoring of providie-r performiance and ot the effects on

health outcomes. For this purpose, the MOH plans to invest in an imlproved inforrmation system for

the HIT and to strengthen its manageinent and planning capacity.

1.10 Restoring fiscal stability is only the first step in the MOH's refolm plan. The next

immediate priority is to reverse the decline in the standards of car-e resulting from a dleteriorating

capital stock. This is an absolute necessity if the health system is to move from an over-reliance on

tertiary care to primary care while preservilln its Credibility amonlg the IO)LpIlatiOn. Complete

4/ For a milorc dbctil(d asscssnienit he I(Ii Hll sc: ApIenIiix I ,,1 theC PI') 1eCC i 11I.einCeiIlt I0nII PlanII (Annex I).

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renewal and updating of the capital stock would be an extremely expensive undertaking and can onlytake place over many years. The Ministry has decided to start selectively with equipment for primarycare, and essential equipment for emergency and hospital trauma and acute care services.

1.11 Finally, the MOH is aware that tight cost controls could result in a deterioration ofservices, and thus of health outcomes. To ensure that this does not happen, the HIll will develop asystem to monitor the effects of cost containment on health indicators.

C. Rationale for Bank's Involvement

1.12 The Government's reform has been both adequate and successful in meeting theGovernment's objectives. It has been an effective tool in reducing the financial deficit and in shiftingresources from curative to primary and preventive care. The reform, therefore, provides a soundbasis for new investments. To sustain the reform, investment resources are badly needed. A Bankoperation would provide the needed support and would he consistent with our overall social sectorobjectives and with the recommendlations of the "Croatia Social Sectors and Social ExpendituresReview". It would also lay the foundation fior follow-up investments for improving hospitalmanagement and expanding primary health care. A Country Assistance Strategy, scheduled for early1995, will identify the health sector as a priority fior public investment.

11. THE PROJECT

A. Proiect Ohiectives and Components

2.1 The primary goal of the Health Pro ject is to support and sustain the Government'shealth care reform program. To achieve this goal, the specific objectives of the Project are to:(a) improve the operational and financial management system of the Health Insurance Institute bysupporting the computerization of information systems, (b) improve the quality of the health caredelivery system by providing laboratory and diagnostic equipment for primary health care facilitiesand basic equipment (and training in its use) for hospitals and emergency services, and (c) improvethe health status of the population hy supporting health proinotion programs. Specific projectoutcomes to measure the success in meeting these objectives are included in the ProjectImplementation Plan (PIP) (see Annex I. pages 37-38). The Project will consist of the followingthree components:

Health Insurance Administration (estimated hase cost US$13.9 million). This component willimprove health insurance administration by (leveloping the information technology networklinking central, district and branch offices of the HII: and hy introtducing "credit card" stylehealth insurance identification cards.

Primary Care and Health Promotion Services (estimated hase cost US$14.9 million). Thiscomponent will improve the qLuality and availability ot' basic diagnostic services for theprimary care network through the provision ot' stan(lard diiagnostic equiplment (x-rays, simplelabs, and mammographic equipment), as well as the requiUred triaining for mendical, nursing.and paramedical personnel. It will also intensit'y programs to prornote healthier lifestylesamong the popuilation through the training andL support otf cominunity health promotion teams.primary care providers, and school teachers, anL through mass me(lia education programs.

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Essential Hospital and Emergency Services (estimated base cost US$19.3 million). This

component will upgrade essential acute care services through the provision of basic equipmentfor the emergency medical system, intensive care units, and perinatal care units in selected

hospitals, as well as related training for medical, nursing. and paramedical personnel.

2.2 Facilities receiving equipment through the Project will he required to repay the cost of

the equipment to the HII through a leasing scheme over a period equal to the estimated economic life

of the equipment (e.g.. eight years for x-ray equipment). Assurances to this effect were provided at

negotiations. Payments will be made to the HIl through an automatic deduction, on a monthly basis.

from fees earned by the facility under the health insurance scheme. At the end of the payment

period, the equipment becomes the property of the facility, which can continue to use it for as long as

it remains functional. This financing mechanism is consistent with a basic principle of Croatia's

insurance scheme that holds the facility responsible for capital costs (which are in fact incorporated

into the fee structure). It also builds an incentive ftor the receiving facility to maintain the equipment

properly and to limit the demand for equipiment to the most cost-effective items, as well as creating

liquidity for future investments.5 The scheme also ensures that the financial impact to both central

Government and the HI] will he neutral. As a condition ftor negotiations. the Government prepared a

draft standard contract acceptable to the Bank. to be signed between the Hil and receiving facilities.

During negotiations, assurances were obtained that, as a condition of effectiveness, a subsidiary

agreement would be signed between the Government and the HIl.

B. Project Description

2.3 Health Insurance Administration. The early success of cost containment eftorts would

not have been possible without the intensive level of monitoring, reporting and control established at

the Hil. These operations have been carried out with the benefit of information systems that are well-

designed but largely dependent on manual data-processing technologies. The Hil has prepared a

comprehensive Strategic Plan for computerization of its information systems. including links between

headquarters and district and larger branch offices, and (at a later stage) between HII offices and

health facilities.L` A pilot project to design and test a computerized system for HIl's operations at

headquarters and in three district and three branch offices (including collection, registration, payment

and control as well as its own internial management) has been launchedl. Systems design was

completed with assistance from information technology experts contracted tor this purpose, and an

international com)petitive hid for implementation of pilot activities, including acquisition of software

and hardware products, has been awardled recently. This pilot phase is expected to he completed by

February 1995. During 1995. the tested technologies will he established in all local offices, and

filling of databases on payers and insur-ed persons will take place. DuL-inlg, the same year, a FinancialProgramming Package to help manage financial assets and cash tlows of the HIl will he designed and

tested, with roll-out to other offices scheduledl to take place in 1996.

.5/ Tllis is possihrlc sillcc Hil will Ihc rcoivcrInig t1I. CSt I)( cqIMlllll1t hiascd on .n dcpr.ciationi s.'cliŽdule wiliclh is

cmisicicrahIv sliortcr tIi:in tiltc rcayinciiti seliclle i tlwc pJ.r p.t Iain

6/ An assessincnt ht (e stratcgic plan is includcd in tlc Prnoct 1lilcs 'Asscssinienl it the Hcalth Insurance Instittite'.

preparcd hy thic pre-appraisal inissimin

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2.4 The HIT is also planning to replace paper insurance cards currently in use with "creditcard" style identification cards to improve data recording and minimize fraudulent card production.At the same time, it would shift to a nationwide unique personal identifier numbering systemnecessary for creating a single database.2' Health facilities will he provided with machines to takeimprints from the cards, with operational efficiencies expected from more reliable data capture.

2.5 The Project will finance the cost of computerization of HIT operations at headquartersand HIl local offices, including the development, pilot and implementation phases. Emphasis hasbeen placed on ensuring that effective implementation training is provided so that expected operationalbenefits are realized quickly. It will also finance the cost of card production and of 5,000 machinesto take card imprints; these machines would be distributed to health facilities and primary careproviders. The Project will also finance studies leading to further information technology investmentsin health facilities.

2.6 To help the National Institute of Public Health (NIPH) in its task ot collecting,publishing and analyzing data on health services and health outcomes, the Project will provide supportto the NIPH to carry out a study to detine the minimal health data set required for its needs, anddetermine which data would he provided by the Hil and which by health providers reporting directlyto the NIPH. A small informatics package will also he provided to upgrade its information system.

2.7 Under this component, an assessment of cost-effective interventions in the healthsector will be carried out in an effort to assist policy makers to make rational resource allocationchoices in the future. Selected individuals will be trained to assess the impact of health careinterventions in terms of health outcomes and to determine the unit costs of these interventions. TheMOH has already commissioned the Medical Association (with its 50-odd member professionalsocieties) to prepare case management protocols for each major health problem, aimed at identifyingthe lowest cost solutions to each problem. The Project will support development of these protocols,which will be compiled and published as a set of guidelines for practitioners. They will also he usedas the basis for determining priorities and resource needs and refining the Strategic Plan. Byinvolving the professional societies and the Medical Association, the MOH hopes to build hroaderconsensus around the restructuring process and hence greater cooperation from practitioners.

2.8 Primary Care and Health Promotion Services. The Project will provide medicalequipment to enable first-line physicians to broaden the scope of their activities, and training to raisetheir level of professional competence, thereby improving the popuilation's access to a hroader rangeof services and reducing the need for patients to go to hospitals.

2.9 The Project will provide radiology e(luipment (standard and specialized x-ray) tohealth centers where no such equiipment is availahle or where the equiLpment has deteriorated. TheProject will also provide selective laboratory equLiipment. Selection of recipient facilities has beenbased on a detailed survey of the current status of equlip,ment in individuial centers and on othercriteria, including access to the nearest alternative facility with satisfactory equiipment. number otinhabitants using the health center and adequate premises tor installing the e(qui,pm-nenlt. It is

7/ The Bank supports thle necd tti havc za singlc uniqulel persomail ]sillfnieali(in .svsiii or health serviecs, t;axadministration, and social scciritm The Govcrnnicni is in thie process ii i snuchi o imiimihrilng S stecn.and it is now under rcvicw

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anticipated that roughly ten percent of the equipment will be allocated to health facilities which servethe refugee population from Bosnia-Herzegovina. (A complete list of equipment is included inAppendix I of the PIP.)

2.10 The Project will organize short-term training seminars for users of the aboveequipment (medical technologists, radiologists, etc.) beyond the training included by the vendor.Training seminars will also be organized for GPs/Family Practitioners and primary care nurses in thecatchment areas of facilities receiving equipment on ways to optimize cost-effective use of the newdiagnostic tests. In addition, extra-residency posts in existing Family Practice training programs willbe financed and reserved for candidates who would be committed by contract to working indesignated underserved areas.

2.11 Health promotion activities in the Project will target three important lifestyle factors --diet, smoking, and physical and sexual behavior -- and will take place in schools, in primary carefacilities and through the mass media. Experience from ongoing programs such as the Health-Promoting Schools and Healthy Cities programs will he extended to larger areas of the country. Inaddition, television and radio programming, currently limited by a lack of resources, will beintensified. A survey on health-related behavior will be carried out at the start of the Project todocument regional differences in health-related behavior, to help identify specific target groups andrefine messages, and to serve as a baseline for monitoring programs. The Project will then organizetraining seminars for the principal channels of action for health promotion: community healtheducators, school teachers, and primary care providers. Supporting materials for health educators.including audio-visual equipment for schools and health facilities, will he provided. The Project willalso provide resources to contract professional services for the design. production and diffusion ofmedia programs.

2.12 Essential Hospital and Emergency Services. Maternal and childcare servicesperformed well -- up to Western European standards -- until recently. Since the war in 1991-92, a

slight deterioration in the perinatal mortality rate, and specifically in neonatal mortality, has beendetected. However, vaccination rates remain high, and most women continue to receive medical careduring pregnancy. Available data show that poor performance is concentrated in parts of the countrywhere there is a lack of qualified personnel (especially neonatologists) and/or equipment. To reversethis declining trend, an effort will be made to improve early identification of women with high-riskpregnancies and assure their transfer to well-equipped and staffed facilities before delivery. TheProject will provide equipment in primary care facilities and district hospitals to improve pre-nataldiagnosis, and resuscitation and acute care of comipromised new-horns. Training of additionalspecialists in the fields of obstetrics and neonatology will also he providedl by financing extra-residency posts in existing specialty prograins for candidates contracted to work thereafter for a setnumber of years in designated understaffedl hospitals.

2.13 At present, emergency medical services are fragmented, of uneven qjuality, and withpoor coverage (especially for highway traffic in tourist routes along the coast). To reduce the deathrates from accidents, injuries, heart attacks and other medical emergencies, the MOH seeks to re-organize emergency services into a nationwide network with standard procedures. quicker responsetime, and more complete and even coverage. The Project will assist in the following areas:(i) communications, by providing radio and telephone equipment ftor a national communicationsnetwork that would extend coverage of the existing '94' emergency telephone number to all parts ofthe country and improve contacts with emergency units; (ii) transport. by the ac(quisition of

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ambulances to replace out-of-date vehicles that are expensive to maintain or those destroyed duringthe war; (iii) clinical equipment, by replacing out-of-date essential resuscitation equipment forambulances; (iv) personnel, by training staff of emergency units and by financing extra-residencyposts in existing specialty programs for Emergency Medicine: and (v) organization, by developingfleet deployment strategies and clinical protocols at emergency centers.

2.14 Although the total number of intensive care beds in the country is sufficient,organization of services is fragmented, with several Intensive Care Units (ICUs) often existing withinone hospital under different departments. In addition, equipment is sub-standard (outdated or notfunctioning) and there is a shortage of medical personnel trained in Intensive Care Medicine.Available data indicate that performance is poorer (i.e., mortality is higher) in hospitals wherestaffing and/or personnel skills are inadequate, especially in district hospitals. The Project will reduceavoidable mortality, morbidity and health service costs resulting from sub-optimum intensive careservices through a reorganization and re-equipping of these services in selected hospitals. Respiratorsand monitors will be provided in selected hospitals. In addition, medical staff qualified in intensivecare will be increased. Selected medical staff will receive fellowships for training in Intensive CareMedicine both in- and out-of-country, over and ahove that currently provided, and continuingeducation programs for paramedical personnel will he organize(l. Hospitals receiving projectresources will be required to re-organize intensive care beds and make a decision on the medical lineof authority for these services (e.g.. by appointing a chief of intensive care services).

C. Environmental Impact

2.15 This is a Category C Project: "No appreciahle environmental impact". Replacementof old equipment (such as x-rays and labs) that presents a health risk will contribute to improvingenvironmental safety. Although waste disposal is not a significant problem, updated protocols fordealing with waste management will he introdticed.

[ll. PROJECT COSTS. FINANCING, MANAGEMENT AND IMPLEMENTATION

A. Introduction

3.1 This chapter provides a summary of the Pro ject Implementation Plan (PIP) which wasprepared in conjunction with the Borrower and reviewed and deemed satisfactory by the Bank. ThePIP includes detailed information on the project description, costs, financing, management andimplementation arrangements, procurement, disbursements, audit reporting. and status of preparation.The PIP is attached as Annex 1.

B. Proiect Cost

3.2 The total cost of the Health Project is estimate(d at ahout UJS$54.0 million, or aboutKN 277.3 million equivalent, including contingencies, taxes and duties. The total base cost isestimated at US$48.1 million. Physical contingencies are estimated at US$3.7 million. Pricecontingencies between negotiations (December 1994) and the end of the four-year pro jectimplementation period will amount to about lJS$2.2 million, or tive peercent of hase cost. Theforeign exchange component is estimated at ahout US$35.0 million, including contingencies, or about65 percent of total project cost. Taxes and dILties are estimate(d at UlS$0.8 million equivalent. Goodsand external services coming in under the Project will he tax exem)pt.

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3.3 The total project cost includes fellowships, training, technical assistance, studies,computer hardware and software, medical and office equipment, teaching and public educationmaterials, refurbishment of facilities, and incremental recurrent costs incurred during projectimplementation. The estimated cost distributed among project components is shown in Table 3 of thePIP. Project costs are summarized by expenditure category in Table 4 of the PIP. The project costsinclude about KN 26 million or US$5. I million to cover incremental operating costs directlyattributable to the Project during the four-year implementation period. Equipment operation andmaintenance, and materials and supplies account for most of the project's incremental recurrent costs.

C. Project Financing

3.4 The proposed Bank loan of US$40.0 million will finance 75 percent of total projectcosts, comprising 100 percent of the foreign exchange cost (US$35.0 million) and 28 percent of thelocal cost, excluding taxes (US$5.0 million). The HIl will finance the balance of project costs(US$14.0 million), including duties and taxes. Incremental operating costs comprising equipmentmaintenance services and annual maintenance costs of computers and software (US$5. I millionequivalent), will be financed entirely by the HII. Averaged over the Project life, this represents lessthan one percent of the projected 1995 operating budget for the HII.

3.5 To assist the HIT in recruiting specialized consultants and conducting the surveysrequired for project preparation, a Project Preparation Facility (PPF) of US$350.000 was madeavailable by the Bank in October 1994. Repayment of the Project Preparation Advance is included inthe project costs.

3.6 The HIl has also requested retroactive financing of tp to US$4.0 million to coverexpenditures incurred up to 12 months prior to loan signing to support the following activities:(a) initial procurement of health care equiptment, and (b) technical assistance for the health promotionsurvey.

D. Administration of Proiect Funds

3.7 The Bank Loan of US$40.0 million will be made to the Government of Croatia. TheGovernment will enter into a subsidiary Loan Agreement with the HII (signing of the subsidiary LoanAgreement will he a condition of effectiveness.) On-lending terms to Hil will he the same as theterms of the Bank's loan to the Government. Hil will provide counterpart funding of about US$14.0million from its own revenues. i.e.. payroll taxes. Hil will he responsible for servicing the Loan tothe Government.

E. Proiect Managemnent and Implementation

3.8 The Project will he im)plementedl over a t'our-year period hy the Hll. In view of Hil'sstrong implementation capacity, which has been demilonstrated during pro ject preparation, a separateproject implementation uinit is not envisaged. Nevertheless, a ftull-tiine Project ImplementationOfficer (PIO) has been appointed by the HIl to coordinate the day-to-day activities during projectimplementation. The HIl will also make available the necessary staff to imiplement the Project. Thesewill include two procurement specialists, an accountant. informatics technical staff, and relatedsupport staff. The Assistant Minister for Economics and Planning. MOH. has been designated asProject Coordinator. In this capacity, the Assistant Minister will provide linkage between the MOH,

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whose primary function is that of policy-maker, and the HII, whose function is to carry out MOHpolicy.

3.9 A Project Advisory Committee, headed by the Project Coordinator, has beenestablished and support personnel to be assigned to project implementation have been identified. TheAdvisory Committee will be responsible for providing policy advice and guidance during the projectimplementation period. The Committee consists of the HII Director, and the team leaders of the sixworking groups which prepared the project proposals. The Advisory Group will be assisted byspecial task forces which it will convene as necessary, for example, to draw up detailed specificationsof equipment, design training programs, or develop health promotion campaigns.

3.10 The Project will require about 17 weeks of Bank supervision per year during the four-year implementation period.

F. Proiect Procurement Arrangements

3.11 Items to he proctired will he groupe(d into major packages to encourage competitivebidding and permit bulk procurement. The standard procurement table is shown in Tahle 6 of thePIP. Procurement will be carried out in accordance with World Bank Guidelines. Majorprocurement categories include: ahout US$31.3 million to be procured through internationalcompetitive bidding (ICB) procedures, US$0.6 million through international shopping (IS): andUS$0.1 million through local shopping (LS). Local procurement will be in accordance withprocedures acceptable to the Bank. It is also expected that US$1.4 million will be procured throughdirect contracting (books, intellectual property, and software development). Procurement packages.including estimated cost and time ot completion, are presented in the PIP.

3.12 Appropriate Bank standard bidding documents will he used tOr the Project. The PIPcontains a detailed list of equiptment packages to he procured Linder the Project. A descr-iption of thecapacity of the implementing agency to carry out procurement is found in the PIP.

G. Disbursements

3.13 The proposed Project is expected to he disbursed over a period of four years, which isconsiderably shorter than the relevant profile in the Region (about seven years). The shorterimplementation period is possible due to the strong implementation capacity of the HIl and thecommitment of the MOH. In addition, the Project is designed to he simple. There is only oneimplementing agency with two products: equipment ancd training. To ensure that the implementationschedule is realistic. agreement has already been reached on detailed eqJuipnment lists and tenderdocuments. The closing date will be December 31. 1998. A sumimiiary of the (lishuisemilent plan isshown as Table 9 of the PIP.

3.14 To facilitate timely project implementation. the Governmiient will establish, maintainand operate, under terms and conditions acceptable to the Bank. a Special Accouint denominated in USdollars. The authorized allocation will he US$3.0 million. However, during the initial stage of theProject, an amount limited to US$2.0 million will he deposited. When the aggregate amount ofdisbursement reaches US$10.0 million, the amount deposited in the Special AccoLunt will he increasedto the full authorized allocation of US$3.0 million.

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3.15 All disbursements against contracts tor goods and services exceeding US$200,000equivalent will be fully documented. For expenditures below that level, disbursements will be madeon the basis of certified Statements of Expenditure (SOEs). This documentation will he madeavailable for the required audit as well as to Bank supervision missions, and will be retained by thePIO for at least one year after receipt hy the Bank of the audit report for the year in which the lastdisbursement was made.

H. Project Audit Reporting and Evaluation

3.16 Project Accounts and the Special Account will be audited in accordance with theBank's "Guidelines for Financial Reporting and Auditing of Projects Financed by the World Bank"(March 1982). The PIP shows the detailed plan for Project Auditing.

3.17 The HIt will prepare semi-annual descriptive and financial reports on each projectcomponent, objective and activity (beginning from the date of Loan Effectiveness). A mid-termreview of the Project will be carrie(d OUt in Octoher/November 1996. The PIP shows the detailed planfor Project reporting and annual reviews.

l. Status of Preparation

3.18 During preparation, the MOH established six working groups which prepared detailedproposals for each component. The World Health Organization (WHO) worked closely with theworking groups in developing these proposals. Based on the proposals, the detailed PIP wasprepared. The organizational structure for project implementation as described in the PIP has beenestablished.

3.19 Implementation and coordination responsibilities hetween the MOH. HII, and theAdvisory Group have been defined. The principal staff for implementation are in place and aresupp(orted by technical staff within the Hil. The PIP includes a detailed description of the pro'jectcoordination and implementation responsibilities.

IV. BENEFIT AND RISKS

A. Benefits

4.1 Health prormotion activities, together with increased early screening for chronicdisease, will contribute in the long run to a reduction in premature mortality, particularly fromcardiovascular disease and cancer. Primary care and essential hospital and emergency equipment to beprovided under the Project will he installed selectively in areas where the infrastructure is mostoutdated or insufficient. This will improve the quality and acceptability of care, as well as value formoney of services and will make a substantial contr-ibution to health gains through a reduction inmortality and morbidity from accidents. acute meedical emergencies and perinatal complications.There will also be improved cost effectiveness by shifting part of the care from the secondary andtertiary levels to the primary levels. Improvements in health insurance administration will facilitatefinancial control and monitoring ot the effects of financial controls on health outcomes. Tangibleimproveinents in care will strengthen the credihility of the on-going refoirm efforts.

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B. Risks

4.2 The Project itself does not face many project-specific risks. The reform policy for thehealth sector is being implemented by a team which commands respect on all sides of the politicalspectrum. Preparation for implementation and procurement is far advanced, which should lead togood disbursement performance. The main risk remains, unfortunately, a coiuntry risk stemmingfrom the unresolved status of the zones currently not controlled by the Croatian Government. Thissituation creates ongoing tension which could erupt in renewedl hostilities, and WouILI no doubt delaythe successful implementation of this Project. While most observers consider the risk of majorhostilities on Croatian territory to be small, it is not insignificant. On the other hand, the Croatianauthorities have repeatedly ciommitted themselves to a negotiated settlement. and over the last twoyears, have shown great interest and willingness to cooperate with the international community. Theyhave also honored all their obligations to the Bretton-Woods institutions and have embarked on anactive program of cooperation with the IMF, the IBRD ancd the EBRD which has already madle twoimportant loans, paralleling our own effiorts. The substantial economic gains achieve(d through thestabilization and reforrm prograimi are in fact strengthening the long-term prospects tor a lasting peace.

V. AGREEMENTS REACHED AND RECOMMENDAI'ION

5. 1 The following actions aire required to assil-e suLCesstLil implementation of the Projectand attainment of the broader project objectives.

5.2 Prior to negotiations, the Government t'ulfilled the following conditions:

(i) A draft stan(lard contract acceptable to the Bank was preparedl to he signed betweenthe HIll and facilities receiving e(quipment (para. 2.2):

(ii) a full-time Project Implementation Officer was appointed (para. 3.9); andL(iii) the Advisory Committee inclUding support personnel was established (para 3.9).

5.3 Durin, negotiations, assulances were provided that:

(i) facilities receiving e(uiLpment under the Project will repay the cost oit e(luipment tothe HIl (para. 2.2)

(ii) a full-time Project Implementation Officer- will he mainitaine(d within Hll during theexecLution of the Project (para. 3.8); andl

(iii) the Advisory Cominittee will he mainitainedl within MOH during the execution of theProject (para. 3.9).

5.4 As a condlition of effectiveness, a subsidiary Loan Agreement Would he signedlbetween the Governmenit andL the Hii (para. 22 ).

Recommendation

5.5 Suhject to the ahove, the proposed operation provides a suitahle hasis for a loan otUJS$40.0 million to the Government ot the Republihc of Croatia.

- 13 -Annex 1

REPUBLIC OF CROATIA

HEALTH PROJECT

PROJECT IMPLEMENTATION PLAN (PIP)

Table of Contents

Page No.

INTRODUCTION

I. THE PROJECT

A. Project Objectives . . . . . . . . . . . . . . . . . . . . . 15B. Project Description .... . . . . . . . . . . . . . . . . 15

II. IMPLEMENTATION ARRANGEMENTS

A. Organizations Responsible for the Project . . . . . . . . . 16B. Agreements between Borrower and

Implementing Agencies . . . . . . . . . . . . . . . . . . 16C. Responsibilities of Implementing Agencies . . . . . . . . . 17D. Functions of Implementing Agencies . . . . . . . . . . . . 20E. Implementation Arrangements . . . . . . . . . . . . . . . . 21F. Interagency Coordination . . . . . . . . . . . . . . . . . . 23G. Role of the World Bank . . . . . . . . . . . . . . . . . . . 24H. Administrative Arrangements . . . . . . . . . . . . . . . . 24

III. PROJECT FINANCING AND COSTS

A. Detailed Financing Plan . . . . . . . . . . . . . . . . . . 24B. Project Costs . . . . . . . . . . . . . . . . . . . . . . . 25C. Procurement Arrangements and Schedule . . . . . . . . . . . 29D. Disbursement and Financing Schedules . . . . . . . . . . . . 33E. Audit Timetable .... .. . . . .. . . . .. . . . . . . 33

IV. DETAILED IMPLEMENTATION ACTIVITIES

A. Detailed Project Activities ... . . . . . . . . . . . . . 34B. Implementation Schedules .... . . . . . . . . . . . . . . 37

V. MONITORING AND EVALUATION

A. Development Indicators . . . . . . . . . . . . . . . . . . . 37B. Project Indicators . . . . . . . . . . . . . . . . . . . . . 38

Appendices:

Appendix 1: List of Equipment to be Procured . . . . .39Appendix 2: Cost Tables . . . . . . . . . . . . . . . . .40Appendix 3: Implementation Schedule . . . . . . . . . . .44Appendix 4: Input-Output Tables . . . . . . . . . . . . . . . . 49Appendix 5: Health Financing and Expenditure Data . . . . . . . 51

Charts:

Chart 1: Health Insurance Institute - Flow of Funds . . . . . 17Chart 2: Organization of Project Implementation . . . . . . . 18Chart 3: Implementation Responsibilities and

Additional Resource Requirements . . . . . . . . . 19

- 14 -Annex 1

Page No.Tables:

Table 1: Financing Plan by Component . . . . . . . . .25Table 2: Financing Plan by Financier . . . . . . . . .25Table 3: Total Cost by Component . . . . . . . . . . . . . . . 26Table 4: Total Cost by Expenditure . . . . . . . . . . . . . 26Table 5: Total Cost by Component and Expenditure . . . . . . . 27Table 6: Procurement Arrangements . . . . . . . . . . . . . . 29Table 7: Summary of the Procurement Packages

for Works and Equipment . . . . . . . . . . . . . 30Table 8: Summary of the Procurement Packages

for Technical Assistance . . . . . . . . . . . . . 32Table 9: Disbursements by Year . . . . . . . . . . . . . . . . 33

- 15 -Annex 1

REPUBLIC OF CROATIA

HEALTH PROJECT

PROJECT IMPLEMENTATION PLAN

Introduction

1.1 This Project Implementation Plan (PIP) was prepared during pre-appraisal and agreed with the Ministry of Health (MOH) and the HealthInsurance Institute (HII). The PIP is based on findings of the pre-appraisalmission and the detailed Project Proposals prepared by six working groupsestablished under the supervision of MOH in accordance with terms of reference(TOR) provided by the Bank. The above-mentioned proposals have been reviewedand found to be satisfactory to the Bank. 1/

I. THE PROJECT

A. Project Objectives

1.2 The overall aim of the Health Project is to support and sustainthe Government's health care reform program which was initiated in 1990.Specifically, the objectives of the Project are:

(i) to improve the operational and financial management systemof the HII by supporting the computerization of informationsystems;

(ii) to improve the quality of the health care delivery system byproviding laboratory and diagnostic equipment for primaryhealth care facilities and essential equipment for hospitalsand emergency services as well as relevant training; and

(iii) to improve the health status of the population bysupporting health promotion programs.

B. Project Description

1.3 The proposed Project will provide computer hardware and software,medical equipment, fellowships, study tours, training, technical assistance,public education materials, and incremental recurrent costs. The total costof the Project is US$54.0 million, of which US$40.0 million will be financedby the Bank. The Project will be implemented over a period of four years bythe HII under the supervision and guidance of MOH, and in collaboration andcoordination with local HII offices, hospitals, primary health care units andthe National Institute of Public Health (NIPH).

The Project has three components:

(a) Health Insurance Administration

1/ A copy of the Government's detailed Project Proposal is available in theProject files and may be obtained from EC1/2HR.

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(b) Primary Care and Health Promotion Services(c) Essential Hospital and Emergency Services

II. IMPLEMENTATION ARRANGEMENTS

A. Organizations Responsible for the Proiect

2.1 Since this Project is designed to support the Government's on-going health care reform program, a separate project implementation orcoordination unit is not envisaged, given the implementation capacity and thecommitment of the agencies involved. The Project will be implemented by theHII, through a Project Implementation Officer (PIO), directly reporting to theDirector of the HII. It was agreed with the Government and the HII that thePIo, who is now in place, will work full-time within the HII for the durationof the Project. To ensure coordination between the MOH and the HII, theAssistant Minister of Health for Economics and Planning has been appointed bythe Minister of Health to act as the overall Project Coordinator.

2.2 The Project Advisory Committee, headed by the Project Coordinator,will be responsible for providing policy guidance during the implementationperiod. The Committee comprises the Director of the HII, and team leaders ofthe six working groups which prepared the project proposals.

B. Agreements Between Borrower and Implementation Agencies

2.3 The Borrower is the Government of the Republic of Croatiarepresented by its MOF. It has been agreed that the MOH will delegate theimplementation responsibility to the HII. 2/ The HII will implement theProject in collaboration with the related units of MOH, NIPH and health careunits. Assurances have been obtained from the HII administration that adequatefunding, based on the project financing plan, will be made available in atimely manner and necessary steps will be taken to expedite the procurementprocedures related to major equipment. The HII developed detailed contractualarrangements between the HII and the receiving health care units as acondition of negotiation.

2/ A detailed assessment of the organization of HII and its implementationcapacity is included in the Project Files and may be obtained fromEC1/2HR.

Annex 1

C. Responsibilities of Implementing Agencies

2.4 Health Insurance Institute: Overall responsibility forcoordination and implementation will rest with the HII. The HII is headed bya director, assisted by a deputy director, and reporting to a ManagementCouncil consisting of nine people, all recommended by the Minister of Healthand appointed by the Cabinet. The HII has a function-based organizationalstructure. There are four major departments headed by a senior managerreporting to the deputy director: (i) Legal Affairs Department dealing withlegal issues including personnel, administrative and operational activities;(ii) Financial Affairs Department dealing with planning, budgeting,controlling and financing activities including accounting; (iii) MedicalIssues Department dealing with public and environmental health issues andmedical audit; and finally (iv) Organizational Issues Department responsiblefor the development and control of physical and architectural standards forhealth care units 3/ and informatics. Currently, the HII has about 2,000staff, down from roughly 3,000 in 1993. The HII central office is in Zagreb.There are 21 Regional Offices. Revenues for 1994 are estimated at 1.6 billionDMs of which three percent is used to cover the HII's administrative expenses.Expenditures are expected to be about 6 percent of GDP in 1994, down from 8.4percent in June 1993. Over 90 percent of expenditures of HII are financed byearmarked payroll contributions. Chart 1 shows the sources and uses of fundsfor the HII.

Chart 1: HEALTH INSURANCE INSTITUTE

Flow of FundsREVENUES

Pension Fund(30%)

Self-employed,farmers, and HII a/ State BudgetUnemployment overhead and Transfer b/Fund (14%) Admin cost (1%)

(3.5%)

PayrollContribution

(55%)

EXPENDITURES

Pharmaceu- Primary Secondary/Ter- Sickness, materticals Health Centers tiary care d/ nity sup, other(15%) (20%) c/ (47%) charges (15%)

a/ 3 of hind is uscd for adminiistrative overhead.hl Maternity henefit (up to onie year). This is the only hbidgel transtr tlo HI fritiom Stlte budgetc/ Capitation (based on population).d/ Fee for services with financial zap.

Note: Individual employee contrihUtions to the HIl consist of: 13.5% tor pensiotn: 7.5% foir health: 2.5% lor children; and2% for uneimiploymiient, for a total of 25.5%. The employer contribiti ion almost dCueICs thc oeVCrall percentage.Farmiers anil self-employed contribuite 11 I %and 15 %. respectively. to the Hil.

3/ The HII has undertaken this responsibility on behalf of MOH.

- 18 -Annex 1

2.5 From the operational point of view, the Project will beimplemented by the existing departments of the HII with limited technicalassistance provided. In each department of the HII, a contact person will beidentified to work for the proiect full-time, and report to the PIO.Additional permanent staff will be needed for some of the sections as a resultof the project investments, specifically for the Informatics Section andEconomics Department. Charts 2 and 3 show the organizational arrangementsrelated to project implementation.

Chart 2: ORGANIZATION OF PROJECT IMPLEMENTATION

MINISTER OF HEALTH

AO&zsVPY 1 1 ASSISTANTMINISTERCOMA 1/77~ (PROJECr COORDINATOR)

PFIOJE ~~~SUPPOATIMP. OFF. UNIT

[ lito u u ft A* l l l

= ; SdeFt ~~~~~~~~~~~~~.__. ..._ .. .|1 I c* -" I ~~~~~~~~~...........

Chart 3: IMPLEMENTATION RESPONSIBILITIES AND ADDITIONAL RESOURCE REOUIREMENTS

ADDITIONAL RESOURCECOMPONENT ACTIVITY IMPLEMENTING AGENCY REQUIREMENTS

PROJECT MANAGEMENT Implementation of prolect Activities Health Insurance Institute 1 F.T. Project Imp. Otficer1 F.T. Adm. Assistant2 F.T. Procurement SpecialistStudy Tours for senior officers

Component 1: HII. Dept. of Financial AffairsHEALTH INSURANCE INS. Procurement of Hardware and Informatics Unit 5 PS for technical support

Software Installation/Testing Adm. Operations Unit 1 PS for O&MReceiving Institutions On-the-job Training for users

Component 2: HII. Dept. of Financial AffairsPRIMARY HEALTH CARE Procurement and Installation of Contacting Unit

Equipment Adm. Operations UnitReceiving Institutions On-the-job Training for users

HEALTH PROMOTION Design and Implementation of Health MOH, NIPH, Schools and Health Care Training for key personnel/Promoting Programs Units Trainers/School Teachers/

Health Personnel

Component 3: Procurement and Installation of HIl. Dept. of Financial AffairsESSENTIAL HOSP. SERV. Equipment Contacting Unit

Adm. Operations UnitReceiving Institutions On-the-job Training for users

EMERGENCY SERVICES Procurement and Installation of HII. Dept. of Financial AffairsEquipment Contacting Unit

Adm. Operations UnitReceiving Institutions Long-term Training for Users

F.T. - Full time staff P.S. - Permanent Staff

xD

- 20 -Annex 1

2.6 Project Implementation Officer (PIO): A full-time PIO who reportsdirectly to the director of the HII is now in place and will be responsiblefor the daily execution of the Project activities. The PIO will be supportedby technical staff from the HII. Limited external technical assistance willbe provided through the Project during the implementation, mainly in thedevelopment and implementation of procurement procedures and organization ofoverseas training programs, considering the limited experience of HII in theseareas.

2.7 The Project Advisory Committee will be active at least until thecompletion of the Project. The members of the Committee have been appointedby the MOH upon the recommendation of the Project Coordinator. The number ofmembers of the Committee, units/agencies to be represented in the Committee,and the frequency of meetings may be revised as required, upon therecommendation of the Project Coordinator. The duties of the AdvisoryCommittee are given in Part D.

2.8 Responsibilities of implementing agencies and the additionalresource requirements needed to undertake the project-related activities andfuture investments of the Government are given in Chart 3.

D. Functions of Implementing Agencies

2.9 The functions of implementing agencies are:

(a) Advisory Committee:

(i) to set the policies, strategies and targets in order to ensure theachievement of the project objectives, and review them asrequired;

(ii) to provide guidance and advice to the Project Coordinator on thetimely implementation of the project activities;

(iii) to ensure the coordination of public and private agencies involvedin the implementation of the Project;

(iv) to set the principles and procedures to be applied in coordinatingwith international institutions; and

(vi) to coordinate the activities of the six working groups.

(b) Project Coordinator:

(i) to oversee project activities to ensure the successful and timelyimplementation of the Project;

(ii) to ensure that financial resources required under the Project aremade available to the implementing agencies in a timely manner;and

(iii) to chair the Advisory Committee.

(c) Project Implementation Officer:

(i) to undertake responsibility for the daily implementation of theProject;

(ii) to monitor project expenditures and costs (local and foreign),process loan disbursement applications in collaboration with the

- 21 -Annex 1

Central Bank of Croatia, and track disbursements of the Bank loanand Government funds;

(iii) to ensure the consolidation of requests and procurement of goodsand services, in accordance with World Bank Guidelines;

(iv) to ensure the preparation and distribution of consolidatedperiodic reports to the relevant government and otherparticipating institutions, including the Bank, reflecting:(a) the status of implementation progress, problems encounteredand corrective actions needed; and (b) current costs of eachproject component and estimated costs of completion;

(v) to ensure the timely preparation and submission to relevantgovernment institutions and the Bank of annual audit reports ofproject expenditure and accounts;

(vi) to ensure the movement of official documents and contracts throughthe usual approval processes and undertake measures to expeditetheir release;

(vii) to coordinate preparation of detailed specifications andprocurement documents for approved equipment lists, review of bidpackages and evaluation of offers received; and

(viii) to ensure the preparation of the Project Completion Report (PCR)within six months after the completion of the Project.

(d) Receiving Institutions (PHC units, hospitals, regional and districtoffices of HII) will be responsible:

(i) to prepare detailed needs assessments, implementation programs andproposed plan of repayment for each category of input that theyare going to receive through the Project;

(ii) to monitor and report on detailed procedures, implementationschedules, and program(s); and

(iii) to review and revise implementation targets and financialresources needed to support future actions.

E. Implementation Arrangements

2.10 Since the components of the Project are closely linked to eachother, some of the activities under each component will be combined duringimplementation. Specifically, the medical equipment to be procured for thePHC units, hospitals and emergency units under the second and third componentswill be combined into several packages of tender in order to shorten thetendering procedures and offer attractive packages for larger suppliers.

2.11 The following procedures have been developed for each component ofthe Project:

(a) contractual arrangements between the borrower and the receivinginstitutions for the equipment;

(b) tendering procedures for different categories of equipment;

(c) procedures related to the organization, delivery and monitoring ofin-service training programs to be provided for large numbers ofpeople in each target group;

- 22 -Annex I

(d) principles and procedures for hiring external long- and short-term consultants; and

(e) procedures/protocols for coordination with other national orinternational organizations.

2.12 The implementation arrangements for Project components are:

(a) Health Insurance Administration:

(i) Overall implementation responsibility for this component will restwith the Informatics Department of HII. Under the coordination ofthe PIO, the Informatics Department, supported by procurementspecialists and qualified technical staff to be hired under theProject, will be responsible for the development of technicalspecifications in accordance with Bank Guidelines. The procurementof hardware and software will be undertaken by the HII Departmentof Economics in cooperation and coordination with the InformaticsDepartment. This unit will also be responsible for providingcontinuous support to the receiving institutions during theinstallation and testing of hardware, loading of software andtraining of the users in coordination with the suppliers.Securing the compatibility of hardware and software and thecoordination between suppliers will be the responsibility of theInformatics Department.

(ii) The tendering package for the hardware should include theprovision of consumables for the project period.

(iii) A number of fellowships and study tours will also be providedunder this component for the staff of HII. The criteria andprocedures for awarding fellowships should be developed incoordination with the MOH and the universities. The candidates forthe fellowships and the study tours that will be provided for themanagerial staff of HII and the MOH will be selected by theAdvisory Committee upon the recommendation of the PIO and approvalof the Bank.

(b) Primary Care and Health Promotion Services:

(i) This component has two separate programs: (i) procurement ofequipment for PHC units and (ii) health promotion. overallimplementation responsibility for the first program will rest withthe Department of Economics of HII and with the NIPH for thesecond program. Under the coordination of the PIO, the Departmentof Economics, supported by procurement specialists to be hiredunder the Project, will be responsible for the development oftechnical specifications, in accordance with Bank guidelines forthe procurement of equipment. This unit will also be responsiblefor providing continuous support to the receiving institutionsduring the installation of equipment and training of the users.

(ii) The activities under the Health Promotion program will beimplemented by the NIPH in coordination with: the Ministry ofEducation, for the training of school teachers and disseminationof information; health care units for the training of key healthpersonnel and dissemination of information; the Croatiantelevision for the broadcasting of television spots and programs;and local administrators for the dissemination of public educationmaterials. External technical assistance will be needed for theproduction of public health education materials, radio andtelevision programs, brochures, leaflets and posters and audio-visual materials.

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(c) Essential Hospital and Emergency Services:

(i) Overall implementation responsibility for this component will restwith the Department of Economics of HII. Under the direction ofthe PIO, the Department of Economics, supported by procurementspecialists to be hired under the Project, will be responsible forthe development of technical specifications in accordance withBank Guidelines for the procurement of equipment. This unit willalso be responsible for providing continuous support to thereceiving institutions during the installation of equipment andtraining of the users, in coordination with the suppliers.

(ii) The period of training to be provided for the users under thiscomponent will be longer than in the other programs; 4.5 years forperinatal care; 2 years for pediatrics/neonatal basic care;6 years for pediatrics/neonatal specialized care; and 3 years forparamedical education. These training programs will be in the formof long-term local fellowships to be financed by the Government.Coordination with designated universities will be required in thedesign and delivery of these programs as well as in the selectionand awarding of fellowships.

F. Interaqency Coordination

2.13 The successful implementation of the Project will depend on goodcoordination among several different agencies in the public and the privatesector. The HII component will require close cooperation between the selectedsupplying firm(s) and central and local offices of HII. The Primary HealthCare Services component will require coordination between selected supplyingfirm(s), MOH and PHC units. Health Promotion will require coordinationbetween the NIPH, the Institute for Diabetics, the Teaching Hospital forCommunicable Diseases, the Institute for Cardiovascular Disease Prevention aswell as public and private television and radio institutions. The essentialHospital Services component will require coordination between selectedsupplying firm(s), MOH, hospitals and universities. The World HealthOrganization may be involved in designing health promotion programs andawarding fellowships.

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G. Role of the Bank

2.14 The Project will, on average, require about 17 staff-weeks of Banksupervision per year on average during implementation, as reflected in theproposed supervision plan below:

Timing Staff Weeks Staffing

CY1995 20 weeks Bank resources (20 weeks) of which:- Task manager (7 weeks)- Health Specialist (6 weeks)- Information Specialist (4 weeks)- Operations Officer (3 weeks)

CY1996 17 weeks Bank resources (17 weeks) of which:- Task manager (6 weeks)- Health Specialist (4 weeks)- Information Specialist (5 weeks)- Operations Officer (2 weeks)

CY1997 15 weeks Bank resources (15 weeks) of which:- Task manager (8 weeks)- Health Specialist (4 weeks)- Information Specialist(3 weeks)

CY1998 15 weeks Bank resources (15 weeks) of which:- Task manager (8 weeks)- Health Specialist (4 weeks)- Information Specialist(3 weeks)

H. Administrative Arrangements

2.15 The PIO will be responsible for carrying out all necessaryadministrative arrangements recommended and approved by the Project AdvisoryCommittee. Full-time attention of the relevant senior officers will berequired in development and implementation of the new administrative systems.

III. PROJECT FINANCING AND COSTS

A. Detailed Financing Plan

3.1 The proposed Bank loan of US$40.0 million will finance 75 percentof the total project costs, comprising 100 percent of foreign exchange cost(US$35.0 million), and 28 percent of local cost, excluding taxes(US$5.0 million). The HII will finance the balance of project costs (aboutUS$14.0 million), including duties and taxes which are estimated at US$0.8million equivalent. Recurrent incremental costs comprising equipmentmaintenance services, annual maintenance costs of computers and software, andother non-salary operational costs (US$5.1 million equivalent) will befinanced entirely by the HII. The HII has received a World Bank ProjectPreparation Facility (PPF) of US$350,000 to assist in project preparation.The financing plan is shown in Tables 1 and 2.

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Table 1: FINANCING PLAN BY COMPONENT

--------- US$ MillionGovern-

IBRD ment Total

1. Health Insurance Administration 9.5 5.6 15.12. Primary Health Care Services 12.6 4.4 17.03. Essential Hospital Services 17.9 4.0 21.9

TOTAL DISBURSEMENT' 40.0 14.0 54.0

a/ Including taxes and duties equlivalent to US$0.8 miiillion. Detailed nImhers may not add to totals duLe to roLunding.

Table 2: FINANCING PLAN BY FINANCIER

----- US$ Million -----Local Foreign Total

Health Insurance Institute 14.0 0.0 14.0IBRD 5.0 35.0 40.0

19.0 35.0 54.0

B. Project Costs

3.2 The estimated cost by project component is shown in Table 3.Project costs are also summarized by expenditure category (Table 4) and bycomponent and expenditure category (Table 5). Details of cost estimates ofeach sub-component are given in Appendix 2.

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Table 3: TOTAL COST BY COMPONENT

(925$

(kisana '000) '

% Total % Tel'otal

Base Foreign Base

Local Foreign Total Costs Local Foreign Totra Excbange Cosrts

I Health Insurance Administration 44,142.9 29.462.9 73,605. 29 8,217 3 5.665.9 13,883.3 41 29

2 Primnary Health Care Services 27,541.9 50.241.5 77,783 4 31 5.296 5 9.661.8 14.958.3 65 31

3 Ersential Hospital Services 19,283.2 81,007.3 100,290.5 40 3,708.3 15.578.3 19.286.6 81 40

Total BASELINE COSTS 90,9679 160.711.7 251,679.6 100 17,222.1 30,906.1 48,128.2 64 100

Physical Contingencies 4,001.2 15.391.3 19,392.5 X 769.5 2.959.9 3.729.3 79 8

Price Contingencies 3,668.6 2,605.7 6,274.3 2 1,000.9 1,175.0 2,175.9 54 5

0otal PROJECT COSTS 99.637 7 178.709.7 277,346.4 110 18.992 5 *5.040.9 54.033.4 65 112

Table 4: TOTAL COST BY EXPENDITURE

(kuna 'l00) (US$

'*itOtl)

% % o Tota % % Total

Foreign Base Foreign Base

Locasl Foreigin Total Exchange Costs Local Foreign 'rotal Exchange Cost%

1. Invesrnent Costs

A. Civil Works 1.189.0 216.5 1.405.5 15 1 228.7 41.6 270.3 15 1

B t)ffice Equipment and 22388.8 22,946.6 45,335.4 51 18 4.033.Y 4412. 8.446.7 52 18Materials

C Medical Equiptnent 6.055.9 123.950.4 130.006.2 95 52 1.164.6 23,836.6 25.(01,2 95 52

1). Technical Assistance

I Polcy Development 1.547.4 0.( 1,547.4 () I 297.6 0.0 297.6 0 i

2. Capacity I3uiluling 11.411.0 5,190.7 16.601.7 31 7 2.194 4 996.2 3,192.6 31 7

3 I'roject Manageincnt 2.390.2 0.( 2.390.2 0 1 459.7 11.0 459.7 ° I

Subtotal Tehnical Assistance 15,348.6 5,190.7 20,539.3 25 6 2.951.7 998.2 3.949.9 25 8

E. Truining 29.940.3 (1.() 29,940.3 0 12 5 757.6 (J. 0 5.757.8 0 12

F Fe lloships and Study Tours 11.0 993.4 993.4 100 0 0(1 191.0 191.0 10(0 1

oital Invesicnent Co.-s 74.922.6 153.297 6 228,220.1 67 91 14.136.5 29.480 3 43,616.8 68 91

Hi. Recurrent Costs

A Supplims snd Operations 3.1)59.6 947 7 4.007 3 24 2 588.4 182.2 770.6 24 2

I3 Equipinent () & M 12,985,7 6,466.5 19,452.2 33 8 2,497 2 1.243.6 3.740.8 33 3

lotal Recurrent Costs 16.045.3 7.414.2 23,459.5 32 9 3.085.6 1,425.8 4.511.4 32 9

90.967.9 160,711 7 251,679.6 64 100 17.222.1 30.906.1 48,128.2 64 M1)()

I'hysicol Contingencies 4,001 2 15.,391.3 19,392.5 79 8 769. 5 2.959.9 3.729.3 79 9

Price Contingencies 3,668.6 2.605.7 6,274.3 42 2 1.000.9 1,175.0 2.175.9 54 5

98,637.7 17S.708.7 277,346.4 64 110 18.992.5 35(040.9 54.033.4 65 112

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Table 5: TOTAL COST BY COMPONENT AND EXPENDITURE(USS'000)

Health Prim-ry Emential

lnsurance Hlealth Care hlospital

Ad iniration Services Services Total

1. Invesment Cost

A. Civil Works 0.0 312.3 0.0 312.3B. Office Equipment and Materials 8,360.5 721.4 0.( 9.081.9

C. Medicnl Equipment 0.0 10,570.9 17.921.3 28,492.3D. Technical Auistance

1. Policy Development 132.1 203 5 1.0 335.52. Capacity BuiWing 3,305.3 230.9 0.0 3.536.1

3. Project Mangement 477.5 39.6 0.0 517.1

Subtotal Technical Asiitance 3.914.9 473.9 0.0 4.388.7E. Training 1.1336 3956.6 1S34#.S 6.43#.5F. Fellowships ad Study Tours 98.2 109.7 It0 207.9

Total Invegment Coats 13,507.1 16,144.8 19.269.7 48,921.5

DI. Recurrent Costs

A. Supplies and Opertions 0.( 0.0 868.7 868.7

B. EquipmentO&M 1,629.5 843.7 1.770.1 4,243.3

Total Recurrent Costs 1,629.5 843.7 2,638.7 5,111.9Total PROJECT COSOS 15,136.5 16,988.5 21.908.4 54,033.4

Taxes 309.3 299.5 19/1.9 799.8Foreign Exchange 6.341.6 11.023.9 17.675.4 15.040.9

3.3 Bases of Cost Estimates. Project costs were estimated as follows:

(a) Base Costs. Cost estimates are based on a review of actual costsincurred in similar projects, i.e., Turkey Second Health Project.Additional information was derived from: (a) costs of consultantservices, fellowships and training based on the rates currentlycharged by local, European and North American consultants andtraining programs; (b) recent quotations obtained from suppliersof hospital/medical and computer equipment; (c) applicationssoftware costs from comparisons with ongoing software developmentactivities and estimated requirements for technical books andjournals; (d) building and refurbishment costs from consultants'surveys of the current costs for these items; (e) funds allocatedfor the preparation of studies, estimated on the basis of theaggregated costs of local and foreign specialized services, unitcosts for internal travel and subsistence, and mission estimatesof material and logistic needs; (f) staff-unit costs from currentpublic service salary scales with some adjustments for theremuneration of local technical staff to a level deemedcompetitive with the market for specialized services; and (g) non-salary recurrent costs (materials and supplies) based on currentGovernment rates. All project costs have been estimated in USdollars on the basis of September 1994 prices at the officialexchange rate of KN 5.5892 per US dollar.

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(b) Contingency Allowances. Project costs include a contingency forunforeseen physical variations (US$3.7 million) equivalent to5 percent of the base coBt of technical assistance, training andfellowships and 10 percent for all other project items. Thefollowing rates were used to cover expected price escalation:local costs 2.7 percent for CY95-98; foreign costs 2.2 percent forCY95-98.

(c) Foreign Exchange Component. The foreign exchange component isestimated at about US$35.0 million including contingencies, or65 percent of total project cost. Calculations of the foreignexchange component were derived from an item-by-item analysisresulting in the following: 98 percent for medical and officeequipment, computer hardware and software, books and journals;30 percent for civil works; 95 percent for foreign technicalassistance; and 100 percent for external training. The foreignexchange component in incremental recurrent expenditure wasestimated at 35 percent for the operation and maintenance ofcomputer hardware and software; 35 percent for other equipmentmaintenance; and 25 percent for supplies and operations.

(d) Customs, Duties and Taxes. Goods and external services to bepurchased under the Project will be exempt from taxes and duties.Taxes and duties for civil works and local technical assistanceare estimated at 10 percent. Therefore, project costs include anestimated US$0.8 million equivalent in direct and indirect taxesand duties on goods and services, to be financed by theGovernment.

3.4 Incremental Recurrent Costs. Included in the Project are aboutUS$5.1 million to cover incremental operating costs directly attributable tothe Project during the four-year period. These consist of incrementaloperation and maintenance expenditure for equipment, and supplies andoperations. Measures now being instituted in the health sector to reducerecurrent costs, improve efficiency and increase collection of user chargeswill place the incremental recurrent cost within sustainable limits. Duringimplementation, HII will pay extra attention to monitoring the adequacy ofrecurrent funds for maintenance and operation of facilities and newlyinstituted programs, and take the necessary actions to rectify anydeficiencies.

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C. Procurement Arrangements and Schedule

3.5 Procurement arrangements under the Project are summarized inTable 6 below.

Table 6: PROCUREMENT ARRANGEMENTS(USS Million)

Non-BankCategory of Expenditure ICB OTHER Financed TOTAL

Technical Assistance -- 0.3 h __ 0.3(Policy Development) (0.3) (0.3)Technical Assistance -- 0.5 h __ 0.5(Project Implementation) (0.4) (0.4)

Technical Assistance -- 3.3 h __ 3.3(Capacity Building) (3.0) (3.0)Training, Fellowships and

Study Tours -- 6.6 -- 6.6(2.9) (2.9)

Equipment and Materials 31.3 2.0 4.2 37.5(31.3) (1.7) (0.0) (33.0)

Miscellaneous (PPF) d' -- 0.4 -- 0.4(0.4) -- (0.4)

Civil Works -- -- 0.3 0.3(0.0) (0.0)

Operations & Maintenance -- -- 5. 1 5.1(0.0) (0.0)

Total Financing Requirements 31.3 13.1 9.6 54.0(31.3) (8.7) (0.0) (40.0)

NOTES: Numbers may not add tip duic to rounding.

a/ Figures in parentheses are the respective anmounts rinaalced by the Bank Loan.

h/ Procurement according to Bank Guidelines for Use of Conswltants.

Prudent local shoppin/eoff-the-shelf purchases (aggregate-USSO. I imiillion) of less thanii US$50.000 per contract: direct contractingfor abouit US$1.4 inillion for books and intellectual property: and international shopping (aggregate US$0.6 miilion) of less thanUS5 300,000 per contract.

d/ PPF advance of USS350.000.

3.6 Procurement of Goods. Equipment contracts which are estimated tocost more than US$300,000 equivalent per contract will be procured followinginternational competitive bidding (ICB) procedures in accordance with theBank's "Guidelines for Procurement Under IBRD Loans and IDA Credits" (May1992). Equipment (about 11 major packages) will be packaged according torelated specialized fields. Computer hardware and peripherals will beprocured with careful consideration of hardware compatibility and localavailability of maintenance services. Equipment procured through ICB willaccount for about 83 percent (US$31.3 million) of the total equipment value.The remaining 17 percent of the equipment value will be in packages suitablefor procurement other than ICB. In the comparison of bids for equipment to beprocured through ICB, local manufacturers competing under ICB would receive a

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preference in bid evaluation of 15 percent of the CIF price or the prevailingcustom duty applicable to non-exempt importers, whichever is less, providedthey can prove that the value added to the product in Croatia exceeds 20percent of ex-factory bid price. Computer systems software, cabling andnetwork installation valued at US$1.4 million will be procured on sole sourcebasis, in order to maintain conformity with pre-existing computer systems.Appropriate Bank standard bidding documents will be used for procurement ofgoods and equipment. Table 7 shows procurement packages for goods.

Table 7: SUMMARY OF THE PROCUREMENT PACKAGES FOR EQUIPMENT

Est.Cost Proc. Prepare Award ContractComponent (USS M) Method Tenderine Invitation Contract Completion

Eauipiment

A. Medical1. Med. Imaging 9.0 ICB Jan. 95 Feb. 95 Jul. 95 June 972. Monitors 4.5 ICa Jan. 95 Feb. 95 Jul. 95 June 973. Laboratory 3.3 ICB Jan. 95 Feb. 95 Jul. 95 June 974. Ambulances 2.2 ICB Jan. 95 Feb. 95 Jul. 95 June 975. Incubators 1.0 ICB Jan. 95 Feb. 95 Jul. 95 June 976. Resp./Aspirat. 6.3 ICB Jan. 95 Feb. 95 Jul. 95 June 977. Te