Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No. 11292-RU

STAFF APPRAISAL REPORT

REPUBLIC OF HUNGARY

HEATH SERVICES AND MANAGMET PROJECT

MCH 5, 1993

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

This document has a restficted distribution asd may be used by recpients only in the performanee oftheir ofaiciidl duties. Its contets may not otherwise be disclosed wihout World Bank authinzaion.

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CURRENCY EOUIVALENTS

Currency Unit - Forint (Ft)

AVERAGE EXCHANGE RATES(Forints per US$)

Currency Unit CY1988 CY1989 CY1990 CY1991 1992 1993October January

US$1.00 - Ft 50.413 59.066 63.206 74.735 79.0 82.7

WEIGHTS AND MEASURES

Metric System

FISCAL YEAR

January 1 - December 31

ABBREVIATIONS AND ACRONYMS

CGP - Close the Gap ProgramGMO - Chief Medical OfficerCSO - Central Statistical OfficeCY - Calendar YearEC - Commission of the European CommunitiesECU - European Currency UnitFT - ForintsFY - Fiscal YearGDP - Gross Domestic ProductGNP - Gross National ProductGP - General PractitionerHIF - Health Insurance FundHPD - Health Policy DepartmentHSMP - Health Services and Management ProjectICB - International Competitive BiddingILO - International Labor OrganizationLCB - Local Competitive Biddingo0W - Ministry of Welfare

NBH - National Bank of HungaryNIHP - National Institute of Health PromotionNPHC - National Public Health CenterOECD - Organization for Economic Cooperation and

DevelopmentPAHIP - Pensions Admin and Health Insurance ProjectPHPU - Public Health Program UnitPMU - Project Management UnitPOM - Project Operations ManualSIA - National Social Insurance AdministrationSOE - Statement of ExpenditureTA - Technical AssistanceTOR - Terms of ReferenceWHO - World Health Organization

FOR OMCAL USE ONLY

REPUBLIC OF HUNGARY

HEALTH SERVICES AND MANAGEMENT PROJECT

STAFF APPRAISAL REPORT

Table of ContentsPage Ng.

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

I. INTRODUCTION .1........................ . .

A. General/Sector Background ..... . . . . . . . . . . . . . . 2B. Key Issues ........ .. ... .. ... .. ... .. . 5C. Government Strategy . . . . . . . . . . . . . . . . . . . . . 9D. Rationale for World Bank Involvement . . . . . . . . . . . . . 10E. Role of International Donor Community . . . . . . . . . . . . . 11

II. THE PROJECT.13

A. Project Objectives .13B. Project Description . . . . . . . . . . . . . . . . . . . . . . 13C. Environmental Impact .20

III. PROJECT COSTS, FINANCING, MANAGEMENT AND IMPLEMENTATION . .. . . . 21

A. Project Cost . . . . . . . . . . . . . . . . . . . . . . . . . 21B. Project Financing .25C. Project Management and Implementation . . . . . . . . . . . . . 25D. Project Procurement Arrangements . . . . . . . . . . . . . . . 28E. Project Reporting and Evaluation . . . . . . . . . . . . . . . 33F. Status of Preparation .33

This report is based on the findings of an appraisal mission which visited Hungary in July 1992. Themission, comprising Alexznder S. Preker (Mission Leader, HeaLth Economist, EC1/2HR); Irina Kichi8ina (Le8alCounsel, LEGEC); Leonardo M. Concepcion (Senior Implementation Specialist, EMTHB), Ilona Szemzo (Operations

Officer, ECI1JZR), and Xhalifa Ikrsmullah (Information Technology SpeciaList, ASTIP). Several teams of

consultants contributed substantially to project preparation: Jeffrey Koplan, Richard Feachem, Tim Byers,

Stephen Blount, Ward Cates, llim McPherson, Michael Marmot, Peter Goldblatt, George Rubin and Erkki

Vartiainen (Public Health); Gunnar Scbioeler and Mathias Kalina (Primary Care); Bjarne Rasmussen, Ole

Nielsen, Astrid de Debuchy and John Roberts (Institutional Care); Richard Eskow (Private Sector

Development); Martin McKee and Charles Normand (Public Health Training); Edward Pfieffer (Public Policy);

Gilles Dussault, Richard Southby and George Jobnson (Health Services Management Training); Niels Sentzen and

Jan van Es (Family Medicine Training); lnge Nielsen and P. Nl van Lin (Nursing Training); Ulla Runge

(Occupational Therapy Training); Frank Ibsen (Social Services); and Howard L. Bleicb, Jerome Jackson and

Edna Moody (Management Support Systems). Lia Achsien, Rose Pavis and Sabrina Buffnan (ECZ/2IR) provided

assistance with text processing and copy editing. Task Manager: Alexander S. Preker (ECI/2HR); Division

Cbief: Ralph W. Harbison (ECl/ZHR); Director: Kemal Dervis (EC2DR); Peer Reviewere: Xavier Call (LASUR);

Willy De Geyndt (ASTPH); and William MoGreevey (PHRHN)

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

Table of Contents (continued)

Fagg No.

IV. BENEFITS AND ISKS . . . . . . . . . . . . . . . . . . . . . . . . 35

A. Benefits .... . . . . . . . . . . . . . . . . . . . . . . . 35B. Risks ............................ . 35

V. AGREEMENTS REACHED AND RECOMNENDATION . . . . . . . . . . . . . . . 36

Tables

Table 3.1: PROJECT COST SUMMARY BY PROJECT COMPONENT . . . . . . . . . . 22Table 3.2: PROJECT COST SUMMARY BY CATEGORY OF EXPENDITURE . . . . . . . 23Table 3.3: FINANCING PLAN . . . . . . . . . . . . . . . . . . . . . . . 25Table 3.4: FINANCING REQUIREMENTS BY YEAR . . . . . . . . . . . . . . . 25Table 3.5: PROCUREMENT ARRANGEMENTS ............. ..... . 28Table 3.6: FINANCING PLAN BY DISBURSEMENT CATEGORY . . . . . . . . . . . 31

tChart

Chart 3.1: CHART OF PROJECT IMPLEMENTATION RESPONSIBILITIES . . . . . . 26

Annexes

Annex 1 : Public Health and Disease Prevention . . . . . . . . . . . . 39Annex 2: Close the Gap Program .... . . . ...... . . . . . . . 67Asmex 3 : School of Public Health .... . . . ..... . . . . . . . 73Annex 4 : School of Health Services Management . . . . . . . . . . . . 89Anex 5: Statistical Tables .... . . . ...... . . . . . . . . 103Annex 6 : Detailed Project Cost Estimates . . . . . . . . . . . . . . . 109Annex 7 : Project Implementation Schedule . . . . . . . . . . . . . . . 117Annex 8 : Project Management Unit and Implementation Arrangements . . . 125Annex 9 : Organizational Charts .... . . . ..... . . . . . . . . 131Annex 10: Project Supervision Plan .... . . ..... . . . . . . . 133Annex 11: Technical Assistance Schedule ............... . 135Annex 12: Schedule of Disbursements ... . . . ..... . . . . . . . 141

Glossary of Terms .... . . . . . . . . . . . . . . . . . . . . . . . . 143Bibliography of Materials in the Project Files . . . . . . . . . . . . . 145References.. . ... 147

L : IBRD-23624R ............................ . 149

REPUBLIC OF HUNGARYHEALTH SERVICES AND MANAGRMET P-ROJECT

STAFF APPRAISAL REPORT

Loan and Project Summary

ApRRQWZI: Republic of Hungary

BENEFYCIARIS: Ministry of Welfare (MOW), Public Health Institutions, LocalGovernment Health Services, Medical Universities and theCentral Statistical Office (CSO).

ILAN AMN: US$91.0 Million Equivalent

ITEMS: Fifteen years, including a five-year grace period, at the IBRDstandard variable interest rate.

PROJECT The Health Services and Management Project has two mainOBJECTIVE: objectives: (a) to improve health status by beginning to close

the gap between Hungary and Western European countries and bysupporting the Government's program of restructuring thehealth sector to focus on more effective interventions; and(b) to provide more efficient and higher quality care bystrengthening the institutional capacity of the health sectorin policy-making, management and evaluation.

PROJECT The proposed Project will provide technical assistance,DESCRIPTION: fellowships, training, preparation of studies, development of

health programs, computer hardware and software, medical andoffice furniture, equipment, teaching materials, refurbishmentof facilities and incremental recurrent costs. The Project,which will be implemented over seven years, consists of thefollowing two components:

The Healta Services Development Component (US$62.7 millionbase cost) will support the Government's program ofrestructuring the health sector to focus on more effectiveinterventions through strategic investments in public healthand selected institutional services; it will complementongoing reforms financed by other international donors thataim to strengthen community services, primary care and theprivate health care sector. The Project will support provenaction-oriented approaches to public health, as well as thecreation of a Close the Gap Program (US$14 million base cost)to launch new initiatives in health promotion and diseaseprevention. Tt will also strengthen certain institutionalservices targeted for special attention because of theirdirect impact on Hungary's most pressing health problems.

The Policy-Making and Management Component (US$43.1 millionbase cost) will strengthen the institutional capacity of the

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health sector by: (a) supporting the establishment of Schoolsof Public Health and Health Services Management;(b) strengthening the NOW Computing Center and introducingmanagement support systems in selected institutions;(c) developing the project management capacity of NOW staff;and (d) supporting the preparation of preinvestment studiesfor restructuring hospitals and strengthening specialistservices.

BENEFITS: The Project's ultimate benefit will be improved healthachieved within an environment of tight constraints on publicexpenditures. Mortality and morbidity will be reduced overthe long term, following the implementation of a nationalstrategy to decrease smoking, alcohol consumption andunhealthy diets, and following the improvement of a clinicalresponse capability to related diseases. The quality and costeffectiveness of health care will be enhanced through theswitch in focus from curative hospital care to preventivemedicine and primary care. A new and more effective balanceir. the public/private mix will allow the public sector tofocus on specific areas of clear-cut market failure. Furthergains in efficiency and more effective care will result fromthe improved professional training and better health servicesmanagement techniques introduced through the Project. Thesemeasures will contribute to expenditure control in the healthsector and have important cross-benefits for the companionPensions Administration and Health Insurance Project.

RISKS: The Project's major risks include: (a) the weak institutionalcapacity of the MOW to implement major reforms; (b) the needto create new administrative structures such as the plannednew School of Public Health and School of Health ServicesManagement; and (c) the loss of expenditure control due to theintroduction of performance-related reimbursements for healthcare providers which could jeopardize the financial viabilityof the Health Insurance Fund (HIF). Specific Projectinterventions have been designed to contain these risks. TheSchools of Public Health and Health Services Management willaddress the weak institutional capacity of the health sectorby providing training and fellowships in policy-making,management and evaluation. Extensive twinning arrangementswith similar institutions in western countries and technicalassistance will reduce the risk of establishing newadministrative structures. Management consultants will behired to strengthen project management and to enhance projectimplementation. Finally, policies will be introduced tocontain health care expenditure and prevent a cost explosion.The Bank will conduct a mid-term review of these policies toensure that they will have been effective and that they willnot have had adverse spill-over effects on the state budget.

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Estimated Prolect Costs I/

Local Foreign Total

------US$ Million-----HEALTH SERVICES DEVELOPMENT

1. Public Health 3.8 27.5 31.22. Institutional Care 12.7 18.8 31.5

Sub-Total Health Services Development 16.5 46.3 62.7

POLICY-MAKING AND MANAGEMENT

3. Public Health and Management Training 5.0 5.0 10.04. Management Support Systems 10.5 17.5 28.05. Project Management Unit 0.3 1.7 2.16 Preinvestment Studies 0.0 3.0 3.0

Sub-Total Policy-Making and Management 1S.8 22A 43.1

Total Base Costs 32.3 73.6 105.9Physical Contingencies 3.0 5.5 8.4Price Contingencies 6.3 12.0 18.3

Total Project Costs 41.6 91.0 132.6

Financing Plan Local Foreign Total..... ............. __- 1~

------US$ million-----Government of Hungary 41.6 0.0 41.6World Bank 0.0 91.0 91.0

Total Financing Requirements 41.6 91.0 132.6

Estimated Disbursements

IBRD FY FY93 PY94 FY95 FY96 FY97 FY98 FY99 FYOO

Annual 4.0 6.0 17.3 24.4 16.8 9.0 8.2 5.3Cumulative 4.0 10.0 27.3 51.7 68.5 77.5 85.7 91.0Cumulative as X of Total 4% 11 30X 571 751 85% 94X 100l

/ Detailed numbers may not add up to totals because of rounding.Includes taxes and duties estimated at US$15.1 million.

REPUBLIC OF HUNGARY

HEALTH SERVICES AND MANAGEMENTRWOJECT

I. INTRODUCTION

1.1. Hungary has been experimenting with economic reform since 1968, butit wac not until a democratic Government was elected in mid-1990 that thecountry became fully engaged in introducing a market economy. As a middle-income country, with an estimated per capita income of US$2,690 in 1991 and apopulation of 10.6 million, Hungary has been a front-runner in th3 economictransformation presently taking place in Central and Eastern Europe.

1.2. Although the health sector consumes 5.6 percent of GDP, the healthsystem has been remarkably ineffective in promoting good health and preventingdisease. In fact, the Ministry of Welfare (MOW) and the local goveniments,responsible for provision of health and social services, face a majorchallenge in closing the gap in health status, mortality rates and lifeexpectancy between Hungary and its western neighbors. Life expectancy of 73.7years for women and 65.1 for men is among the lowest in developed countries,and mortality from cardiovascular disease is nearly the highest in the worldand increasing, especially for males in the prime working ages of 35 to 55years. For comparison, life expectancy at birth in Western Europe is around71 years for males and 77 years for females. An important issue facing thehealth sector is the skewed allocation of resources between curative andpreventive services. Extensive, but; poorly targeted, investments during theearly 1970s led to a massive build-up of acute care hospitals and training ofmedical specialists at the expense of adequate primary care, basic diagnosticand therapeutic equipment, long-term care and rehabilitation services.Training of public health specialists, health service managers, generalpractitioners, nurses and many other health care personnel was seriouslyneglected. There are virtually no incentives to motivate patients to maintaingood health and to use scarce resources judiciously, or to encourage healthcare workers and institutions to provide high quality care. The privatesector was, until recently, excluded from nearly all health activities. Therecurrent budget required to operate these ineffective and inefficient healthservices now outstrips the country's financial resources.

1.3. The Government is, therefore, trying to restructure the health sectorin an attempt to improve health status, and in this way, contribute to thealleviation of the grim social conditions left by decades of low standards ofliving, disregard for the environment, unhealthy lifestyles, and misdirectedpriorities in the provision of health and social services. Two closely linkedprojects, this Health Services and Management Project (HSMP), and a relatedPensions Administration and Health Insurance Project (PAHIP), will support thestrategic health sector investments needed to facilitate Hungary's drive forintegration into the market economy of Western Europe.

A. General/Sector Background

1.4. Over the past two decades life expectancy at birth for males hasfallen by 0.9 years and life expectancy at age 30 for males has fallen by 4.2years, despite improved infant and child mortality. Life expectancy forHungarian females has stagnated over the same period. By contrast, WesternEuropean countries have witnessed substantial increases in life expectancy forboth men and women. Infant mortality rates have fallen from 86 per 1,000 livebirths in 1950 to 15.1 in 1991, but remain around double the Western Europeanaverage.

1.5. The core of this bleak situation lies mainly in high and increasingmortality rates from certain non-communicable diseases in adulthood, whichhave exceeded gains from continuing decreases in infant mortality. Age-standardized death rates for men aged 30 to 69 years rose between 1970 and1985 by over 30 percent for all causes and by about 30 percent forcardiovascular causes. The equivalent figures for women were increases ofabout nine percent and five percent, respectively. The major causes, indescending order of importance, of mortality and years of potential life lostin males aged 15 to 64 years, are cardiovascular disease (of which acutemyocardial infarcts are the leading cause) and cancers (of which lung canceris the leading cause) Other reasons for which mortality rates in adults inHungary are strikingl higher than in other European countries include chronicrespiratory disease, tuberculosis, and appendicitis.

1.6. The main characteristics of the Hungarian health sector will bereviewed briefly under the following headings: (a) Health Services(Prevention a:-d Health Promotion; Care in the Community; Treatment inInstitutions; and the Private Sector); and (b) Management (Human Capital andUtilization of Services).

Health Services

1.7. Prevention and Health Promotion. Public health ard diseaseprevention activities are carried out at both national and local levels by theSanitation and Epidemic Prevention System (SANDEPID). SANEPID stations areresponsible for disease surveillance and reporting, control of communicablediseases, monitoring of en7ironmental heal t, food hygiene, health educationand preventive medicine. Among the few tangible achievements of the SANEPIDstations has been their contribution to programs that supply vaccines topediatricians and conduct surveys and follow-up actions for the control ofcommunicable diseases. They are also responsible for traditional publichealth functions such as work place safety, assessing risk levels andenforcing orders to change specific occupational practices. Success in thisarea has been rather limited. More controversial, however, is that manySANEPID stations have microbiological and immunological laboratories whichprovide clinical testing for local hospitals which often do not have their ownservices. In contrast, most public health services found in western countriesdo not provide clinical laboratory services for hospitals.

1.8. I ;ar it She Comq . The Hungarian Health Service is comprised ofa highly structured network of health care institutions that providecomprehensive care for over 90 percent of the population. Additional parallelhealth services are provided by other Ministries,l/ public enterprises,medical cooperatives and a small private sector. The MOW is responsible forformulating health policies, planning, monitoring and evaluation, andproviding a limited range of highly specialized tertiary care and medicaleducation. Hungary is one of the few countries in Central and Eastern Europeto have embraced, in principle, the World Health Organization's (WHO)Declaration of Alma Alta (1978), and the Health For All 2000 which have settargets for primary care throughout the world. The primary care network,2/under the responsibility of local government (Ministry of Interior), wasdesigned to be the first point of contact for individuals and families,bringing health care as close as possible to where people live and work, andproviding a critical link in continuity of care (4,537 catchment districts foradults and 1,445 for children). The present case load is 2,282 people pergeneral practitioner (GP). Ideally, the primary care network provides acomprehensive range of preventive, medical and social care to all ages, andcoordinates more sophisticated interventions at higher levels of care. TheMOW is trying to improve this system by upgrading the training of familydoctors and other primary care workers, / and introducing a new set ofincentives to improve the quality of community care (local governmentresponsibility, privatization of assets, and performance-based capitationpayments for family doctors).

1.9. Treatment in Institutions. After the Second World War, most WesternEuropean countries put a high priority on developing and expanding hospitalservices. Hungary, and most other Central and Eastern European countries,went through the same development during the 1970s, putting a premium onachieving arbitrary normative standards in the number of beds and doctors percapita, but have not enjoyed the economic growth necessary to sustain thisactivity. This has led to a massive expansion in hospitals, out-patientclinics and mediral centers without an adequate recurrent budget. By 1990,there were 101 beds per 10,000 population (71.3 active beds), which is in thehigh range of values observed in the OECD.A/ Although these beds weredesigned for acute care, many are used for long-term cases due to a shortageof chronic ,are beds and related support services elsewhere in the system.Hospitals are large, undifferentiated and multi-pavilion complexes that aredifficult and expensive to run (often 1,500 to over 2,000 beds, spread outover several blocks). In 1990, ownership of most hospitals, clinics and

1 Other Ministries that provide parallel health services include Ministry of Transport (rallways),Ministry of Industries (occupational health), Ministry of Interior (polcea), Ministry of Defense(armed forces), Ministry of Justice (prisons) and Ministry of Foreign Affairs (embassies).

2/ An effective primary care network comprises general practitioners tGPs), coumunity nurses, healthvisitors, social workers end allied primary health oare workers.

See the discussion on Human Capital below.

_/ This bed/capita ratio does not include additional beds found in the parallel health services provided

by other Ministries.

diagnostic centers was transferred from the MOW to local governments under theIbinistry of Interior. Major capital investments are still financed by theMOW, but all recurrent expenditure, including renovations and repairs forlocal government health services, is financed by the Social InsuranceAdministration (SIA). During the past two years, construction of hospitalsand clinics has largely ceased due to a marked reduction in the investmentbudget for the health sector. Some medical drugs, syringes, gloves, needles,small instruments and electronic equipment (much of which is imported ordepends on imported inputs) are now in short supply.

1.10. The Private Sector. For four decades, the state dominated nearly alleconomic activities in Hungary and systematically excluded the private sectorfrom playing a significant role in the financing, ownership and provision ofhealth services. The MOW is now actively supporting the new Government'seconomic reform program to stimulate private markets and reduce the size ofthe state by encouraging privatization of: (a) family doctors offices;(b) ambulatory diagnostic clinics; (c) non-hospital-based therapeuticfacilities; (d) pharmaceutical producers, wholesalers and retailers; and(e) enterprises that manufacture medical supplies and equipment. Some successhas been observed in privatizing small businesses. Major joint venturesbetween western firms and Hungarian polyclinics, hospitals and pharmaceuticalmanufacturers have, however, been much more sporadic. Private supplementaryhealth insurance plays virtually no role in the financing of health care,although direct out-of-pocket expenditure (mainly as co-payments for drugs andunder-the-table gratuities) is estimated at 20 percent of total health careexpenditure, indicating a future capacity for development in this area.

Management

1.11. Human Canital (Providers). Since the 1970s, the total number ofdoctors, nurses, dentists, and pharmacists per capita has increasedsignificantly to reach a doctor/population ratio that is within the mid-rangefor the OECD, and similar to that found in many other Central and EasternEuropean countries. By 1990, the health services employed 202,600 people(33,400 in full-time active posts while the rest work on a part-time basis orin non- clinical-related posts). There were 29.3 doctors, 3.6 dentists, 3.4pharmacists, 53.8 nurses and midwives per 10,000 inhabitants. The alliedhealth care worker/doctor ratio, nurse/doctor ratio and nurse/bed ratio arelow by western standards. The mix of medical personnel is characterized by apredominance of specialists, even at the primary care level, where internists,gynecologists, pediatricians and dentists provide the first point of contactwith the health system. Over 76 percent of doctors are specialists, and morethan 50 percent of these have a subspecialty. Unlike other Central andEastern European countries, Hungary has a small, though insufficient, formaltraining program to prepare doctors for general practice or family medicine.Training for different roles in the health workforce starts at one of threelevels: vocational secondary schools; worksite training and apprernticeship;and university level. Vocational secondary schools and worksite training havebeen combined under one category called middle-level education, and universityeducation has been categorized as high-level training. Entry to medicalschool is limited by quotas and competition among applicants. The MOW isresponsible for financing the educational components of doctors' training

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while the SIA indirectly finances the service components in terms of the goodsand services used by students while they rotate through various clinical wardsof teaching hospitals. Most non-medical training is under the responsibilityof, and financed through, the Ministry of Education.

1.12. Utilization of Services (Consumers\. Utilization of health servicesin Hungary is high compared with many Central and Eastern European courtries.On average, a person in Hungary visits a physician 14 to 16 times per year(including dentists), compared with a range of 2.0 to 12.8 physician visitsper person reported in the OECD. Cross-boundary flows from neighboringcountries, which may account for as much as 3 million people, and unreportedvisits to private doctors and parallel health services may cause significantdistortions in these utilization patterns. In 1990, the number of hospitalbed days per capita was 2.8 in Hungary, compared with a range of 0.1 to 4.9 inOECD countries. The average length-of-stay in hospitals was in the mid-rangeof patterns in Western Europe (9.9 days in active hospital beds and 32.2 daysin chronic beds); occupancy rates were 74.9 percent and 84.6 percent,respectively. Long queues, waiting lists, low-quality services, and supplyshortages observed in the health ser-vices can be explained largely on thebasis of an imbalance between the needs or demands of the population and theability of the health services to manage its scarce resources effectively andefficiently (drugs, equipment, materials and supplies).

B. Key Issues

1.13. The key issues that will be addressed by the HSMP, as well asparallel projects supported by other international donors to strengthenprimary care and the private sector, are summarized below under the followingtwo headings: (a) Structural Imbalances (Ineffective Public Health Services,Low Quality Primary Care and Social Services; Distorted Priorities withExcessive Hospitalization; and Public Sector Monopoly); and (b) WeakInstitutional Capacity (Early and Narrow Specialization; and Poor Management).

1.14. The health sector in Hungary inherited both strengths and weaknessesfrom the previous regime. Extensive social protection against the risks ofillness, tirough access to a comprehensive range of health services for thewhole population, is a notable achievement.5./ Considerable accomplishmentswere also made in communicable diseases control, and maternal and childhealth.

1.15. The business of health care should ultimately be to produce goodhealth. In this respect the health sector has failed to fulfill its centralmandate. Hungarians have the worst health in Europe, with health statusdeclining relative to western countries since the 1950s and trailing behindother Central and Eastern European countries (see Annex 1). This issurprising in view of the fact that, among former socialist states, the

5/ Entitlement to a comprehensive ran8e of benefits bas bee universal since 1975. Physical access wasgreatly improved tlzoub investments and trainm of doctors during the 1970s.

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country has the highest health care expenditure relative to national income(5.6 percent of GDP), and among the highest number of doctors and acute carebeds per capita. Leading causes of the health g±p between Hungary and itswestern neighbors are well known: half of the adult population smokestobacco; the diet is exceptionally high in saturated fat and salt; andhypertension is not controlled. The population is pessimistic about itsability to change these and other risk factors.

.16. Disillusionment and impatience with the speed of the reform processhave led to both unrealistic expectations for the future and toccunterproductive nostalgia about the past. This creates a difficult dilemmafor reformers. A political backlash against the socialist framework forproviding health care has created a strong popular demand for a fresh start onall fronts. Without careful reflection about both previous achievements andfailures, there is a great risk of throwing out the good with the bad.Furthermore, the move to a market economy has created a false expectation thatall the perennial problems of the past will be fully eradicated in the future,including poverty, illness, disability, ignorance and resource constraints.

Structural Imbalances

1.17. Ineffective Public Health Services. Though public health agencies inmany countries have played an important role in reducing the prevalence ofchronic disease risk factors, the SANEPID public health system was ineffectivein controlling environmental pollution and in reducing lifestyle risk factors,partly as a result of an inability to influence legislation, policy or publicattitudes, and partly because of the prevailing attitude that "to measure theproblem is to solve the problem." In the past, the deteriorating healthstatus of the population was known by the Government but not revealed forpolitical reasons. Today, the Government recognizes that health promotion andprevention are the means to reducing morbidity and mortality, but clear actionhas not been taken to implement effective programs to combat these problems.

1.18. The current health sector is not structured effectively to addressthe huge deficit in public health. To close the gap in health status betweenHungary and Western Europe, it will be necessary for Hungary to develop abetter balance between its public health, primary care and hospital services.The public health service was reorganized in 1991 to create a largehierarchical organization out of the pre-existing array of institutions. Thefunctions of individual institutions were not fundamentally reviewed and,without additional reforms, the new service will not have the capacity todesign and implement the range of primary and secondary preventive programsthat will be essential to improving health status.

1.19. Preventive services are especially vulnerable during the presenteconomic crisis because they are likely to have their budgets cut to aproportionally greater extent than curative services. Even if some existingpublic health structures could easily be closed without risk to the health ofthe population, cuts in other areas could undermine the continuation ofessential and effective services for women and children (e.g., immunizationand prenatal care), and could delay or prevent the launching of newinitiatives in such areas as family planning. Legal abortion is still usedextensively to limit fertility due to a lack of information and access to

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alternative and affordable methods of birth control. Improved information onmortality, risk factors and cancer incidence will be necessary to guide andevaluate the preventive programs proposed by the reforms.

1.20. Low Quality Primary Care and Social Services. In principle, Hungaryhas embraced the concept of primary health care like many other counxries.The country has a long way to go, however, before realizing this obj'-tive inpractice for several reasons: (a) there is a widespread cultural reliance onspecialized and institutional care; (b) resources in the primary care settingare inadequate; and (c) true political commitment to reorienting the healthsector towards primary care still needs consolidation. It is more prestigiousand financially rewarding for medical doctors to work in hospitals andspecialized clinics than to work in the primary care setting where basicequipment, supplies and drugs are often inadequate. Access to diagnosticfacilities is often difficult, and generalists find their work isolated fromtheir hospital-based colleagues. The narrow range of clinical skills of non-hospital-based doctors, who were often trained as specialists, makes itimpossible for primary care services to function properly. As a result,general practitioners do not play an effective role in screening, secondaryprevention, or risk factor counseling. Patients rightfully feel they arewasting time in queues only to be told that adequate equipment or supplies islacking. They want their diseases treated as quickly as possible, by the bestexpert available, and are willing to pay substantial gratuities under-the-table to be referred quickly to higher, but inappropriate, levels of care.Ambulances are frequently used to transport non-urgent cases because patientsknow it will gain them easier access to hospitals than if they went on theirown. Developing a stronger commitment to primary care will be critical to re-orienting the health sector in the future towards more effective and qualitycare.

1.21. The boundaries between health care and social services have importantimplications for costs and quality of life, especially in the area of long-term services for the handicapped and impaired elderly. The social servicessystem is run largely by local governments and includes neonatology nurses,social workers, day homes for the aged and home social care. There is littleformal coordination between social services and the health sector to promotedeinstitutionalization through planned discharges and case management. Theresulting lack of chronic care facilities leads to excessive use of hospitalsfor social care (20 to 30 percent and above in some cases). Improvedfunctional links between the various forms of ambulatory and institutionalcare, and between health and social services, are necessary to make theprimary health care system less fragmented and to strengthen the continuity ofcare it was designed to provide.

1.22. Distorted Priorities with Excessive HosRitalization. The capitalinvestments and recurrent expenditure required to upgrade institutional careto western standards are far beyond the financial resources that will beavailable to the health sector in the near future. Under the previous system,the NOW relied on policies drawn up at the supra-ministerial level in the formof five-year national plans. Many imbalances developed because of a lack ofclear priorities in matching scarce resources with urgent needs for acute andchronic care, and for rehabilitation services. An excessive belief ineconomies of scale led to the construction of massive multi-pavilion hospitals

and polyclinics. Most of the advantages of size were lost through poorcommunication between pavilions, poor integration among different levels ofcare and additional costs of paying for duplications in utilities. Large1,500- to 2,600-bed hospitals make visiting by families and doctors difficult.Lack of same-day surgery, pre-admission testing and post-discharge home careresults in excessive and inappropriate reliance on institutional care. Withthe transfer in ownership of most hospitals from the MOW to loca) governments(under the responsibility of the Ministry of Interior), the notion of centralplanning and setting priorities disappeared altogether. Every local hospitalnow wants the latest in technology and a full range of subspecialties.Despite present resource constraints, some strategic investments in hospitalinfrastructure, training and equipment is necessary to secure more cost-effective treatment for the main causes of morbidity and mortality, and torelieve other parts of the health service of inappropriate activities (e.g.,microbiological and immunological tests performed by the public health servicefor acute care hospitals).

1.23. Public Sector Monopoly. Many of the problems observed in the healthsector today are evidence of the inefficient allocation of scarce resources bya public sector monopoly and over-reliance on central planning. Commoditiesand services that have economic properties like private goods, but that aregiven away free by the state, soon find willing customers on the black market.Major investments in hospitals, expensive diagnostic equipment and capitalintensive projects that require some government intervention to prevent marketfailure, have remained vulnerable to political favoritism. In its attempt tochange this legacy by establishing a new balance in the public/private mix,the MOW is facing several difficult challenges: (a) shortages of knowledgeand expertise in developing and managing private sector activities; (b) aninappropriate policy framework for provider reimbursement schemes, providercontracting, consumer -hoice and quality assurance; and (c) lack of adequateinvestment and seed capital to start new private companies. Out-of-pocketexpenditures, a potential source of recurrent financing for new privateinitiatives, are largely lost through gratuities (not to mention the loss oftax revenues to the Government due to such "black marketn activity). The needto find solutions to these problems is becoming increasingly critical, as thepublic sector retrenches to focus on areas of clear cut market failure wherethe private sector is unable to secure an equitable and efficient allocationof scarce resources (public health, expensive hospital care, and care for theelderly and handicapped). Improved financing of the private sector will becritical to establishing a more effective balance between the public andprivate health sectors.

Weak Institutional Capacity

1.24. Early and Narrow Specialization. Professional training has not keptup with modern trends, especially in fields such as public health and healthpromotion, health services management, primary care, nursing and social work.Quantity in training health care workers was considered a priority during the1970s, at the expense of quality. Early specialization (technical training ofnurses starts at age 14) provides cheap labor, but deprives youths of broaderskills through a more comprehensive basic education. Higher education focuseson overspecialization, reflecting the power base enjoyed by specialists withinthe medical establishment, with little attention given to disciplines such as

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family or community medicine.5/ The training of allied primary health careworkers has been neglected. The low status of general practice and poorincome in the ambulatory setting create strong negative incentives for doctorswho might otherwise be attracted by training in family medicine. Sincemedical universities are still under responsibility of the MOW, rather thanthe Ministry of Education, they are isolated from mainstream universityactivities. The proposed higher education reform in Hungary will change thisin the near future. As a result of these and other factors, postgraduatetraining in public health is narrowly based and inadequate to confront thechallenges presented by the poor health status of the population. Hospitalsare usually under the management of a medical director, economic director andnursing director, none of whom have received training in health servicesmanagement, planning and evaluation. Skilled manpower is the most valuableresource in a health service, and effective training programs are needed toconfront the challenges of the future.

1.25. Poor Management. Health services are poorly managed, relying largelyon manual record keeping and obsolescent technology. Few hospital directorshave access to management-based information systems to evaluate healthoutcomes, performance and expenditure trends, or to assist in record keeping(admission/discharge data), accounting, personnel management, materialsmanagement, equipment management and tracking utilization patterns. Thisprevents policy-makers, managers and other health care professionals frommaximizing effectiveness and efficiency in provision of services. Highlyspecialized clinical workers spend a great deal of their time performingadministrative duties rather than providing medical care. Rigid bureaucracy,with strict adherence to arbitrary norms, deprives directors and healthpersonnel of the flexibility and scope in individual decision-making needed todetermine local priorities and to allocate resources according to specificneeds. As the health sector continues to experience strong inflationarypressures with respect to pharmaceuticals, imported medical technology, and acatch-up in the relative wage of health workers compared with the industrialsectors, and as financial resources decrease in real terms, it becomesincreasingly critical to achieve marginal gains through more effective use ofscarce resources and efficient management. In the near future, whenperformance-based reimbursement for health care providers are introduced, thefinancial viability of many institutions will depend on a skilled and toughmanagement approach to the number of doctors, active beds and balance of care.

C. Government Strategv

1.26. With the election of a democratic Government in mid-1990, Hungaryinitiated a series of significant reforms aimed at stimulating economic growththrough efficient private markets, liberalizing trade and reducing theeconomic role of the public sector (privatization of public assets,deregulation of many spheres of the economy, reduction in the state budget bysix percent of GDP over three years, and reduction in subsidies to no more

h/ The awarding of postgradtate degrees is liited to the Postgraduate Medical School and most primarycarq doctors are specialsts in internal medicine, Synecology end pediatrics.

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than four percent of GDP by 1993). The World Bank and International MonetaryFund have been active partners throughout this process of structuraladjustment.

1.27. In support of the Government's economic reform program, and to adaptthe health sector to the needs of a market economy, the MOW has launched aseries of ambitious programs to restructure the health sector to improvehealth, to provide more effective and efficient services, and to containcosts. Notably, financing recurrent expenditure was transferred from thestate budget to contributory social insurance under the administration of theSIA in 1990. In the future, transfer payments for the non-employed andcopayments will supplement health insurance as a source of health carefinancing. The Local Government Act (1990) decentralized responsibility forownership, management and provision of health and social services to the localcommunity level. The Public Health Act (1991) aims to initiate effectiveprograms to combat the leading causes of poor health. The Primary Care Act(1992) will reorient the health sector towards more cost-effective and highquality basic care. Incentives are being introduced to improve efficiency andproductivity of health care providers. Capitation payments have already beenintroduced for primary care doctors. Hospitals will soon be reimbursed on acase-mix basis. Revisions to the Pharmaceutical Act will continue to reduceunnecessary subsidies for medications and increase cost-recovery.

1.28. An aggressive series of reforms has also been initiated to establisha new public/private mix in the provision of health services, which will allowthe public sector to free up resources for improved targeting in specificareas, as recommended by the Bank's recent Country Economic Memorandum.2/ Alegal framework has been created to privatize the pharmaceutical sector.Provisions are being introduced to: (a) provide loans for private doctors topurchase or rent equipment and premises; (b) facilitate contracting-out ofsome services to the private sector; and (c) establish supplementary voluntaryhealth insurance for above-standard care.

D. Rationale for World Bank Involvement

1.29. World Bank involvement in Hungary's health sector reform is justifiedfor three main reasons. First, expenditure on health services and incometransfers must be contained if the fiscal balance needed to underpin a returnto economic growth is not to be jeopardized.i/ Although such expendituresnow constitute over 22 percent of GDP, several factors threaten to triggerfurther explosive growth in expenditure on health services and cash benefits:(a) economic liberalization has led to an increase in prices and wages;

v/ I8D, Hungary - Refor= gad Decentralization of the Publlc Sector, Volumes 1 and 2, Report No. 10061-HU, January 30, 1992.

I TBRD, Smry Reform and D eentralization of the Publlc Sector. Volumes 1 and 2, Report No. 10061-HU, January 30, 1992; DMW, Sociol Security Reform In Bumaarv, prepared by G. opits, R. Nolann, G.sobieber, and Z. SidgSick, October 12, 1990; and TBRD, Hunterv - Health Services Issues and OptionsIo guos . Iforlkin Paper. Septenber 10, 1990.

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(b) unemployment has led to a growing need for income support programs; and(c) greater freedom and choice have led to less restraint in demand for healthservices. Second, health services and social insurance benefits are financedby an already punishing levy of 37.5 percent on gross wages (about 16.3percent for health services alone). The resulting inflation of labor costsand dampening of the demand for labor are exactly opposite to what Hungaryrequires in order to safeguard its international competitiveness and addressits growing problem of unemployment. Third, illness limits individuals'participation in employment. Reduced incomes due to illness, contribute toincreased poverty, and poverty deprives people of exactly those healthy livingarrangements, diets, and lifestyles which are critical to closing the healthgap between Hungary and western countries. The resulting vicious circle ofillness and poverty, if allowed to continue, will weaken even further thecountry's potential for economic recovery and growth, while at the same timemagnifying the upward pressure on public expenditure.

1.30. Addressing the above issues is an integral part of the Government'sreform program. For these reasons, the Government now proposes: (a) toreorient the health sector so as to provide more effective interventions; and(b) to strengthen the MOW, local governments, and related health careinstitutions to provide more efficient care. To do so, the many deficienciesof the health sector must be addressed in a period of economic crisis, whenpublic sector investments have long been reduced below what is required evenfor maintaining the existing capital stock. As demonstrated by Bank studiesof human resources development in Hungary,2/ and elsewhere in the region,many of the required reform measures will entail substantial capitalinvestment, a large proportion of which will be imports of equipment andexpertise. With funds not otherwise available to the health sector in thepresent economic context, the Project will help finance the most criticallyneeded investments within the MOW's reform program. These investments willresult in only minimal net increases in recurrent expenditures in the short-term, and over the medium- to long-term will contain upward pressure on thestate budget.

E. Role of International Donor Community

1.31. Grant Facilities. Japanese Grant Funds were requested through theWorld Bank and approved in December 1991 for the preparation of the Project.The US$1.1 million grant facility has substantially covered fees and expensesfor consultants' services required to prepare the loan proposal. Thefollowing other international donors also provided financing for technicalassistance during project preparation: American Government, British TrustFund, Canadian Government, Danish Government, Dutch Government and FrenchGovernment. Appreciation is expressed to the following agencies for releasingstaff to provide technical assistance during project preparation: AustralianHealth Insurance Commission, Australian Department of Social Security,

2/ IRD, Hunaarv - The Transition to a Market Economv: Critical Human Resources issues, Report go. 6665-SU, August 6, 1990; IBRD, Hungarv - Reform of the Social Policy and Exuenditure, 1992; and I*RQ.Wuniarv - Roueina Policy Reform in Hungarv. Report No. 9031-EU, November 1990; and the mungary HumanResources Project (Loan 3313-HV) deals only with the education sector and unemployment services.

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Australian Department of Health, Danish Health Board, Finnish Ministry ofSocial Welfare, George Washington University, Harvard University, LondonSchool of Hygiene and Tropical Medicine, University of Minnesota, Universityof Montreal, Urgences Sante and US Centers for Disease Control.

1.32. As agreed with the Government at the onset of Project preparation in1991, the proceeds from a World Bank loan have been reserved for criticalactivities for which such grant facilities will not be available. Independentfinancing has, therefore, also been sought from the international donorcommunity for projects to strengthen social services, primary care and theprivate sector, which are an integral part of the Government's Reform Programfor the health sector. Although originally developed by the World Bank aspart of its global health sector reform strategy, the implementation andsupervision of projects related to the proposed social services, primary careand private sector reforms will be the responsibility of these other donoragencies, not the World Bank.

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II. THE PROJECT

A. Project Objectives

2.1 The Project has two main objectives: (a) to improve health status bybeginning to close the gap between Hungary and Western European countries andby supporting the Government's program of restructuring the health sector tofocus on more effective interventions; and (b) to provide more efficient andhigher quality care by strengthening the institutional capacity of the healthsector in policy-making, management and evaluation.

B. Project Description

2.2 The proposed Project will provide technical assistance, fellowships,training, preparation of studies, development of health programs, computerhardware and software, medical and office furniture, equipment, teachingmaterials, refurbishment of facilities and incremental recurrent costs(US$105.9 million equivalent base cost; and US$132.6 million total costincluding contingencies).2Q/ It will be implemented over a period of sevenyears by the MOW, public health institutions, local government healthservices, medical universities, and the Central Statistical Office (CSO)through the following two components:

(a) The Health Services Develooment Component (US$62.7 millionbase cost) will comprise the following two subcomponents:

(i) Public Health and Disease Prevention; and(ii) Institutional Care.

(b) The Policy-Iaking and Management Comgooent (US$43.1 millionbase cost) will comprise the following four subcomponents:

(i) Public Health and Management Training;(ii) Management Support Systems;(iii) Project Management; and(iv) Preinvestment Study.

2.3 Recognizing that widespread systemic reform in the health sector is along-term process, the Government and the World Bank have agreed that the HSMPwill be the first in a phased series of strategic investments needed toimprove health and adapt the health sector to a market economy. Two aspectsof the Project are especially noteworthy in this respect. First, preparationof the detailed cost tables that are presented in the Annexes was madepossible by the availability of a Japan Grant facility. As in the case of thecompanion PAHIP, these tables reflect an advanced stage of project preparation

J/ Estimated project costs in this chapter are provided without physical or price oontingncies.Dotaled uwber may not add up to totals because of rounding.

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rather than an excessive complexity of the project design itself. Wherepossible, non-critical activities were postponed for futur3 investments. Forexample, the investments required to upgrade hospitals and specialistsservices to Western European standards go far beyond the financial resourcesthat will be available to Hungary in the short- to medium-term. With theexception of a few strategic and highly targeted interventions, the HSMPlimits its involvement in the hospital sector to conducting a preinvestmentstudy of future priorities. Likewise, since the proposed primary care andprivate sector reforms will be supported by other donors, these areas were notincluded in the Project. The remaining technical complexity is inherent tothe proposed health promotion and disease prevention strategy. This has to beaccepted as part of the cost of doing business in the human resources sectors.Second, to emphasize the importance of public expenditure control andHungary's Economic Reform Program, during negotiations, assurances wereobtained that, for the purposes of cost-containment and to protect thefinancial viability of the HIF, the Borrower shall take all necessary measuresthrough budget caps and other expenditure controls, to ensure that theaggregate of all expenditures on health services financed through RIF for agiven year, including performance-related reimbursements for doctors,hospitals and other health care providers, would not exceed the healthservices budget of HIF for that year (total HIF budget net of cash benefitsfinanced through health insurance).

Health Services Development

2.4 This component will support the Government's program of restructuringthe health sector to focus on more effective interventions through strategicinvestments in public health and selected institutional services; it willcomplement ongoing reforms financed by other international donors that aim tostrengthen community services, primary care and the private health caresector. The Project will support proven action-oriented approaches to publichealth, as well as the creation of a Close the Gap Program (CGP) (US$14million base cost) to launch new initiatives in health promotion and diseaseprevention. It will also strengthen certain institutional services targetedfor special attention because of their direct impact on Hungary's mostpressing health problems.

2.5 Public Health and Disease Prevention (USS31.2 million base cost).This subcomponent will seek to improve health status through a series oftargeted investments in health promotion and disease prevention activities(see Annex 1 and 2 for a detailed description). It forms the centerpiece ofthe HSMP by setting priorities for the Government Reform Program based on theleading mortality and morbidity indicators and keeping these at the forefrontof national and local debates about health and health service reforms. Duringnegotiations, assurances were obtained that, not later than June 1, 1993, anew Public Health Program Unit (PHPU) shall be established in the Office ofthe Chief Medical Officer (CNO) and shall be maintained to manage the PublicHealth subcomponent of the Project. The PHPU shall be staffed with a full-time director and project manager, whose experience and qualifications shallbe acceptable to the Bank and who shall be assisted by competent staff inadequate numbers. The PHPU shall liaise with the PHU and collaborate withother implementing agencies.

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2.6 The newly established PHPU in the Office of the CMO will bestrengthened to: (a) manage the public health subcomponent of the Project;(b) manage and disburse the funds of the CGP; (c) analyze and disseminateinformation on public health; (d) develop national, regional and localpolicies on health promotion and public health action programs;(e) advise the CMO on public health priorities; and (f) coordinate itsactivities with the faculty of the new training programs in public health andhealth services management.

2.7 The Project will support the following action-oriented public healthactivities: (a) strengthening of the National Public Health Center (NPHC);(b) chronic disease primary prevention; (c) chronic disease secondaryprevention; (d) school health; and (e) Hungarian health surveys. The NPHCwill be strengthened through a reorganization of its institutions, training,and communications systems. Hungarian-specific interventions in primaryprevention will be designed and implemented to reduce the levels of chronicdisease risk factors in the population. The current health status of theHungarian population and the relationship between behavior and mortality willbe assessed through carefully designed epidemiologic studies in well-definedgeographical regions of Hungary. A strategy of national consensus formationwill subsequently be defined based on the outcome of this demonstration model,leading to Hungary-specific recommendations on future national policies ontobacco, alcohol, and diet. The current anti-smoking program of the NationalInstitute for Health Promotion (NIHP) will be strengthened. Interventions insecondary prevention will be strengthened through an improved cancerregistration system. National screening programs for cervical cancer, breastcancer, colorectal cancer and hypertensive control will be developed. Theresulting secondary prevention strategies will be implemented in appropriateclinical settings. A Health Promoting Schools Project, supported by WHO andthe European Community, will be carefully assessed through a controllededucation experiment in ten intervention and ten control schools using grades5 through 8 as targets for the assessment. If effective, resources will beprovided to expand the program nationwide. Finally, the Project will supporta major health survey to strengthen information on mortality, risk factors andcancer incidence, essential to guiding and evaluating the preventive programsand future investment strategies for health services reforms. The survey willform the basis for an ongoing outcome evaluation of other interventions to beintroduced through the Project.

2.8 The Project will also create a CGP to launch new initiatives inhealth promotion and disease prevention designed to reduce mortality whichwill be supported through funding provided on a highly competitive basis (seeAnnex 2 for a more detailed description). The main objectives of the CGP willbe: (a) to stimulate innovative, acti.on-oriented intervention programs inhealth promotion and disease prevention to control cardiovascular disease,cancer and injuries; (b) to establish a more substantial and incentive-drivenfinancing mechanism for action-oriented intervention programs and research inpublic health; (c) to foster high quality, action-oriented interventionprograms in chronic disease prevention; (d) to make provision for futurepublic health initiatives which cannot be anticipated or launched immediately;and (e) to overcome the pervasive pessimism in Hungary, among the populationand medical profession alike, that effective action in health promotion and

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disease prevention could begin closing the gap in health status betweenHungary and Western Europe. During negotiations, assurances were obtainedthat the Borrower shall apply the criteria, guidellnes and procedures forawards of grants under the COP agreed upon with the Bank, and future changesto, or introduction of, new criteria, guidelinesr and procedures shall besubject to Bank approval prior to their introduction and implementation. As acondition of disbursements, the Bank vill require that no withdrawal shall bemade in respect of payments made for expenditures under Category (3) (Schedule1 of the Loan Agreement) unless Hungarian and international members for theClose the Cap Committee for the COP have been selected on the basis ofcriteria satisfactory to the Bank, and the first committee meeting has beenheld.

2.9 The Project will provide technical assistance (494 staff-months),fellowships and training (147 staff-months), teaching materials, audio-visualequipment, hardware, software, library resources, and development of studiesand interventions designed to empower the public health system to dealeffectively with the challenges presented by increasing rates of chronicdisease. It will also finance the CGP (US$14.0 million base cost) on thebasis of competitive funding of sub-projects prepared, appraised andimplemented in accordance with criteria and procedures agreed with the Bank.

2.10 Institutional Care (USS31.5 million base cost). This subcomponentwill support a balanced short-term remedial approach to addressing the primaryand secondary effects of cardio-cerebrovascular diseases, the leading causesof death and morbidity in Hungary, while the NOW is conducting a more detailedassessment of the investment needs in the hospital sector and specialistsservices.21/ It will upgrade the equipment and buildings of a network ofclearly targeted institutions (local, regional and national) that deal withthe morbidity and mortality of these diseases. Specifically, the subcomponentwill provide diagnostic and therapeutic equipment for: (a) one national andfour regional cardiovascular centers (non-invasive and limited invasivecoronary care services); (b) five selected stroke centers (early detectionequipment); and (c) one national and local rehabilitation service. This willprovide the necessary clinical backup to support, in a balanced manner, thepublic health strategy developed under this project, in addition to theprimary care and private sector reforms that will be developed in parallelunder financing from other donor agencies.

2.11 The Project will provide technical assistance (six staff-months),medical equipment and furniture, and limited civil works to support theacquisition and installation of the needed equipment. It will provide on-the-spot training to strengthen the operation and utilization of the newequipment.

flV Sao details under Preinvuttent Study subcomponent.

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Policy-Making and Management

2.12 This component will strengthen the institutional capacity of thehealth sector by: (a) supporting the establishment of Schools of Public Healthand Health Services Management; (b) strengthening the MOW Computing Center andintroducing management support systems in selected institutions;(c) developing the project management capacity of MOW staff; and(d) supporting the preparation of preinvestment studies for restructuringhospitals and strengthening specialist services.

2.13 Public Health and Management Training (USS10.0 million base cost).This subcomponent will support the Government's initiative to: (a) establisha School of Public Health that will offer a postgraduate training program(masters level) in public health, two-year supervised placements, retrainingfor doctors in the public health service, and fellowships abroad for Mastersand PhD degrees; and (b) establish a School of Health Services Management thatwill offer a two-year postgraduate training program (Masters level) in healthservices management, develop a continuing education program to upgrade theskills of managers, and introduce a research program in health servicesmanagement. Faculty and professional development will be supported throughpostgraduate degree fellowships abroad (Masters and PhD degrees) andparticipation in professional conferences and workshops (see Annex 3 and 4 fora detailed description.) The Project will support reforms in curriculumdevelopment and awarding of higher education degrees in public health andhealth services management, consistent with the higher education reforms thatwill be introduced by the Ministry of Education under the Higher Education lawto be approved by Parliament and supported by the Human Resources Project.

2.14 The Project will provide technical assistance (37 staff-months),fellowships (955 staff-months), training, teaching materials, audio-visualequipment, hardware, software and library resot.ces to establish andstrengthen the described programs. Limited civil works will be required toadapt and refurbish existing buildings to meet the needs of the new programs.

2.15 Management Support Systems (USS28.0 million base cost). Thissubcomponent will strengthen the management capacity of the health sector byproviding policy-makers, planners and managers with modern information systemsand office equipment necessary to gather accurate and up-to-date informationon reasons for visits to health facilities, health services outputs and healthcare expenditure. To strengthen information management within the hospitals,the Project will provide 60 to 70 workstations and four file servers for eachof 25 selected hospitals, based on size and complexity of function. It willsupport development of a Management Information System (MIS) for middle- tohigh-level hospital managers and clinicians, and provide application softwareas feeder systems for the MIS for Admissions-Transfer-Discharge datarecording, chemistry, hematology, microbiology, radiology, pharmacy, newfinancial management modules, electronic mail, and preparation of a mandatedsummary that will be given to the patient and the primary care physician. Thesystem will be developed and tested in five pilot hospitals before deploymentin the remainder of a selection of 20 hospitals over the life of the Project.

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2.16 Parallel to the above activities, all hospitals in the country willbe provided with a basic financial management module to support the proposednew performance-related reimbursement schemes for hospitals and specialistsservices. During the initial phase, hospitals will continue to do stand-aloneapplications such as personnel, payroll, chart of accounts, materialsmanagement, technology management, word processing, spreadsheets, andstatistical analyses freestanding on personal computers. The financial andMIS system will be designed to have the capacity to be expanded, as skillsdevelop and resource-. become available, to include these and other features ofa comprehensive system of clinical computing. A disease monitoring system,using population-based techniques, will be developed later during the Projectto permit routine monitoring of thospital utilization patterns and, eventually,monitoring of the costs and outcome of hospital services provided to definedpopulations.

2.17 Hospital managers will be trained to use the system to trackexpenditures, identify ways to contain costs and operate their serviceseffectively and efficiently. Clinicians will be trained to identify costeffective treatments by combining financial data with information from theadmission/discharge information system. Clerical staff will be trained indata coding, transfers from paper to electronic forms, aggregation of datafrom local to national levels, and analysis and interpretation of data. Thesubcomponents will provide the software and hardware to develop a qualitycontrol system by various medical colleges and institutes.U2/

2.18 The Project will provide technical assistance (184 staff-months),fellowships and training (51 staff-months) to support development of theapplication software. The Project will provide the necessary hardware,software, office equipment and limited civil works for offices that willaccommodate the new activities.

2.19 Protect Mana2ement (USS2.1 million base cost). This subcomponentwill strengthen the capacity of the PhU to coordinate projects in the healthsector, supported by the World Bank and other donor agencies. During theearly phases of implementation, services of project management consultantswill expose the PMU to modern project management techniques such as: controlof critical paths, monitoring resource utilization, overseeing ; y-to-dayoperations, evaluating progress, resolving bottlenecks, preparing periodicprogress reports, and ensuring the timely execution of tasks. Consultantswill provide support in the following areas: (a) ensuring that funds (loans,grants, parallel financing and local counterpart funds), resources (human,physical and information), and management support are made available to theProject when required through appropriate budgeting and planning; (b) managingspecial accounts established for the Project; (c) processing and/or expeditingloan/grant fund withdrawal applications and draw-downs; (d) consolidating andpreparing progress and evaluation reports, financial records, statements ofexpenditure, and audits for the Project; (e) coordinating implementation ofvarious activities to ensure that project objectives are met, and that the

12/ Technical assistance in the form of a feasibility study would be provided under the PreinvestmentStudy suboamponent.

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required actions are executed in an efficient and timely manner in accordancewith the planned project processing and implementation schedule; and(f) undertaking procurement of consultant services, goods and civil works forthe Project to standardize processes and benefits from economies of scalethrough bulk procurement. By the end of the Project, Hungarian managers willhave fully mastered the skills of project management. During negotiations,assurances were obtained that during execution of the Project, the Borrowershall maintain within the MOW the Project Management Unit (PMU) to be headedby a full-time project manager, whose experience and qualifications shall beacceptable to the Bank, and who shall be assisted by competent staff inadequate numbers. For loan effectiveness, the Bank will require that the MOWhas signed a contract to employ a management consultant firm to strengthen thePMU's project management capacity.

2.20 The Project will provide technical assistance (111 staff-months),fellowships and training (six staff-months) until the necessary transfer ofexpertise has occurred, making it possible slowly to withdraw the intensivesupport provided during the early phases of project implementation. It willprovide the necessary hardware, software, equipment and civil works for PMU tooperate effectively.

2.21 Preinyestment Study (USS3.Q million base cost). This subcomponentwill support development of a preinvestment study to prepare for an eventualsecond phase investment in hospitals and specialists services. It will assistthe MOW in clarifying the roles of major partners in the health care systemand other sectors relevant to health. During a first phase of the study, theProject will strengthen the MOW's capacity for policy-making, planning,evaluation, consultation and negotiation by: (a) establishing policy-makingunits at the national, regional and local levels; and (b) providing technicalassistance in formulating and implementing policies and legislation relatingto: (i) health care financing and management; (ii) 'Health for All" policydevelopment and program implementation (interdepartmental, intersectorial andenvironmental); (iii) capital investment; (iv) development of consultation andnegotiation mechanisms as part of the reform process within a democraticstate; and (v) a framework for the development of the nongovernmental privateand independent sector. During a second phase of the study, the Project willconduct a detailed analysis of the physical facilities and equipment, andhuman resources in the health sector with a view to elaborating medium- tolong-term strategies relating to: (a) rehabilitation and improvement ofexisting health services (closures, consolidations and conversions), additionof new capital facilities (construction of major civil works) and introductionof expensive new technologies (equipment, hardware and software); and(b) manpower development (this will include a reassessment of professionaldevelopment, quality control measures, and the function of existingprofessional bodies and institutions).

2.22 The Project will provide technical assistance, fellowships andtraining in the form of pilot projects, feasibility studies and policy advice.It will provide the necessary hardware, software and equipment for the studiesto be conducted in an effective and efficient manner.

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C. Environmental Imoact

2.23 The Project has been classified as C: "No appreciable environmentalimpact." Attention will also be given to appropriate disposal of sanitary,medical and laboratory wastes.

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III. PROJECT COSTS. FINANCING MHANAGEMENT AND IMPLEMENTATION

A. Prgiog. Cost

3.1 Summarv of Project Coxts. The total cost of the Health Services andManagement Project is estimated at about 10.2 billion Forint (Ft) orUS$132.6 million equivalent including contingencies, taxes and duties. Thetotal base cost is estimated at US$105.9 million. Price contingencies betweenappraisal (June/July 1992) and the end of the seven-year projectimplementation period will amount to about US$18.3 million or 16 percent ofbase cost plus physical contingencies. Total contingencies represent25 percent of the base cost. The foreign exchange component is estimated atabout US$91.0 million including contingencies, or about 69 percent of totalproject cost. In an attempt to reduce the scope and complexity of the Projectto a minimum, multiple linked activities that are financed locally through theMOW's investment budget (Ft. 8.7 billion or US$110 million in 1990) wereexcluded from the project design. Had these locally-financed activities beenincluded under total project costs, the foreign exchange component financed bythe Bank would have been even less than the 60 percent ratio recommended forHungary. The total project cost includes technical assistance, fellowships,training, preparation of studies, development of health programs, computerhardware and software, medical and office furniture, equipment, teachingmaterials, refurbishment of facilities and incremental recurrent costsincurred during project implementation. The estimated cost distributed amongproject components is shown in Table 3.1 below. Project costs are summarizedby expenditure category in Table 3.2. Detailed cost estimates of each projectcomponent by category of expenditure are shown in Annex 6.

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

(a) Base Costs. Cost estimates are derived from: (a) costs ofconsultant services, fellowships and training from ongoing technicalassistance (TA) and specialized services in the Human ResourcesProject (Loan 3313-HU) and the Financial System Modernization Project(Loan 3191-HU); (b) recent quotations obtained from suppliers ofhospital/medical and computer equipment; (c) applications softwarecosts from comparisons with ongoing software development activitiesand estimated requirements for technical books and journals;(d) staff-unit costs from current public service salary scales withsome adjustments for the remuneration of local technical staff to alevel deemed competitive with the market for specialized services;(e) building refurbishment costs from consultants' survey of thecosts for these items; (f) funds allocated for the preparation ofstudles, estimated on the basis of the aggregated costs of local andforeign specialized services, unit costs for internal travel andsubsistence, and mission estimates of material and logistic needs;and (g) on the basis of competitive review of sub-projects prepared,appraised and implemented in accordance with criteria and proceduresagreed with the Bank for the COP (see Annex 2). All project costs

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have been estimated in US dollar terms on the basis of June 1992priqes adjusted at the official exchange rate of 79.0 Forint per USdollar (October 1992).

fMle I1: PROJECT COST SUMMARY BY PROJECT COMPONENT

I of 2---- Forint Million --- ---- U8$ million ---- Base ForeignLocal Foreign Total Local Foreign Total Costs Exchange

1. WL1 SlRVIMS m

1.1 Public Health

Strengthening of the NPBC W 91.0 1,311.9 1,402.9 1.2 17.0 16.2 172 942Chronic Disease Primary Prevention 28.8 2586. 285.7 0.4 3.3 3.7 41 902Chronic Disease Secondary Prevention 136.6 142.9 279.5 1.8 1.9 3.6 32 51XSchool Health 32.9 50.3 83.2 0.4 0.7 1.1 12 61SHungarian Health Surveys 0.0 351.7 352.6 0.0 _4.6 ,48 4X lOOS

SubteAal: f 290.2 Z1 319 2 403 L0 9J 3 _ 5 1 2 29X J58

1.2 Institutional Care

Stroke Program 121.6 423.5 545.1 1.6 5.5 7.1 72 786Cardiovascular Diseases 351.5 568.2 919.6 4.6 7.4 11.9 lX 622Physical Rehabilitation 506.1 457 4 963.5 6.e 5.9 12 5 lZX 472

sulitatal 979.2 1 449.0 2,428 Z 12.7 1.8 8 31.5 30X 60S

2. EOICYHMAKM AMD .. ASER8

2.1 Public Health ead Management Trainina

School of Health Services Management 265.5 140.1 405.6 3.4 1.8 5.3 5X 35XSchool of Public Health --- 121.3 245.7 3... 1 16 3.2 _4.8 5X 67X

Subtotal: 386.0 3858 772.7 _ 5.0 _.5J 10J 0 eX 502O

2.2 Management Surort System

NOW Computing Center 57.0 163.3 220.3 0.7 2.1 2.9 32 742Management Information Support System 748.7 1.187.1 1.935.8 __SLt 15.4 _25.1 242 612

Sdbtotal: _80. 1.350.4 2.138.1 10.5 17.5 28.0 261 632

2.3 Project Management Unit

Project Management Unit 24.9 133.8 15J.4 _.9, 1.7 J .1 21 842Subtotal: 24.9 133.8 158.L 0.3 1.7 2.1 2X 84X

2.4 Preinvestment Studies

Preparation of Preinvestment Studies 0.0 231.0 231.0 0.0 3.0_A 3.0 3_ 3X _LOOXSubtotal: 0.0 231.0 231.0 _0.0 3.0 3.0 3X lOO

TOTAL USK CCETS: 2,486.9 58663.6 8,150.6 32.3 73.6 105.9 1002 692Physical Contingencies: 229.7 420.4 650.1 3.0 5.5 8.4 6X 652

Price Contingencies: 487.3 924.4 1.411.7 8.3 12.0 18.3 172 65TOTAL POJECT COSTS: 3.203.9 7.008.4 lO.Z12.3 41.8 91.0 132.6 1251 691

NOTES: Numbers may not add up due to roundins.Project coats include taxes and duties estimated at US$15.1 million equivalent to 12.92 of the costof goods and services except for TA Wich is expected to be tax exempt.

/ Cost includes US$14.0 million (base cost) for the COGP.

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Table 3.2: PROJECT COST SUMMARY BY CATEGORY OF EXPENDITURE

X of %----- Forint million ----- ---- US$ Million ---- Base ForeignLocal Foreign Total Local Foreign Total Costs Exchange

1. Fellowshlpa 0.0 352.6 352.6 0.0 4.6 4.6 41 100lSpecialists 24.1 736.4 760.5 0.3 9.6 9.9 9x 97XTraining 73.9 7.2 81.1 1.0 0.1 1.1 1X 9XStudies/Pzoaram Development J1 00 1 823 .7 1 823 .7 0.0 23.7 23.7 22X 100_

Subtetal: ILV L2.SO 3,017.9 1.3 37Z9 39Z 37 972

2. 1gJ1T MfIBRILS and NOIIIMUEqulpment 170.5 1,189.0 1,359.5 2.2 15.4 17.7 172 87%Computer Systems 351.6 845.7 1,197.3 4.6 11.0 15.5 lS 71XProprietary Software/Books 90.6 136.0 228.6 1.2 1.8 2.9 31 60XFurniture 137lz 10.7 _ 134J4 1.6 J 0J 1 1 7 21 8X

Subtotal: Z73 2.1813 2,917.8 9.6 -28.3 37 9 _ 361 752

3. CILRefurbishing 34. MA 377.5 4.5 0.4 4.9 5S 7S

Subtotal: 349.5 28.0 377.5 4.5 0.4 4.9 5 72

4. nXM AL,BRin aLocal Staff Salaries 261.9 0.0 281.9 3.7 0.0 3.7 3X OXComputer 0&4 162.9 181.3 364.2 2.4 2.4 4.7 4S 502Software Maitenanee 21.2 60.6 61.8 0.3 0.8 1.1 12 742Equipment OCM/spare parts 126.6 90.9 217.5 1.6 1.2 2.8 32 422Building Oam 30.3 1.3 31.5 0.4 0.0 0.4 ox 42Non-salary Operational Costs 660.1 200.3 660.4 8.6 2.6 11.2 lX 232

Subtotal: 1.303.0 534.4 1.837.4 16.9 4.9 23.9 23S 292

0V&L BNM COSIS: 2,486.9 5,663.6 8,150.6 32.3 73.6 105.9 100l 692Physical Contiagencies: 229.7 420.4 650.1 3.0 5.5 8.4 8S 652

Price Contingencies: 487.3 92. .4 1.411. 6.3 12.0 18.3 _17X 652

101 I : .r 3.D.ff3203.9 7.008.4 0 L241 a .3 41 91.0 132.6 1252 69X

NOTM: Rumb rs may not add up due to rounding.Project costs include taxes and duties etimated at U8915.1 million equivalent to 12.92 of the cost ofgoods and servies except for TA.g/ Cost includes US914.0 million (bas eost) for the Close the Gap Program.

(b) Contingency Allowances. Project costs include a contingency forunforeseen physical variations/additions (US$8.4 million) equivalentto five percent of the base cost of technical assistance and staffsalaries, and ten percent for all other project items. Annual ratesof foreign price increases have been estimated at 2.8 percent inCY92, 3.9 percent in CY93-94, and 3.8 percent thereafter. Because ofthe large differential between the estimated annual foreign and localinflation rates, the overall price increases for the Project havebeen calculated on the basis of the estimated foreign priceescalation rates. This approach is justified on the assumption that

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the policy of adjusting the Forint exchange rate to reflect theinflation differential between Hungary and its trading partners willcontinue.l/

(c) Foreign Exchange Co2monent. The foreign exchange component isestimated at about US$91.0 million including contingencies, or about69 percent of total project cost. Calculations of the foreignexchange component were derived from an item-by-item analysisresulting in the following: (a) building works, furniture, localmaterials and supplies--8 percent; (b) medical and office equipment,computer hardware and software--71 percent; (c) books and journals--88 percent: (d) annual licensing/upgrading costs of computersoitware--74 percent; (e) imported materials and supplies--67percent; (f) technical assistance, fellowships, training and studies--100 percent; (g) incremental recurrent costs for the operation andmaintenance of computer hardware--50 percent; (h) equipmentmaintenance--42 percent; (i) local staff salaries--0 percent; and(j) other non-salary incremental recurrent costs--4 percent.

(d) Customs. Duties and Taxes. Project costs include an estimatedaverage 13 percent, or US$15.1 million equivalent, for customs dutiesand taxes on works, goods and services. It is expected thattechnical assistance services for the Project will be exempt fromtaxes.

3.3 In :emental Recurrent Costs. Project recurrent costs includeincremental costs directly attributable to the Project, which will arisemainly from: (a) medical and computer equipment operation and maintenance;(b) maintenance of applications software; and (c) salaries of new faculty andstaff of the two schools. The additional recurrent (base) cost will totalabout US$23.9 million equivalent during the seven-year project period. Atfull operational status of the Project (1997), the annual incrementalrecurrent cost generated is estimated to be about Ft 397 million (US$5.2million equivalent), or about 0.2 percent of the projected 1992 recurrentexpenditure (Ft 184 billion) of the MOV. Measures now being instituted in thehealth sector (including those being supported by the proposed PensionsAdministration and Health Insurance Project) to reduce recurrent costs suchas, among others, cutting waste on pharmaceutical benefits and hospital careby only five percent, will place the incremental recurrent cost withinsustainable limits. During implementation, MOW will pay extra attention tomonitoring the adequacy of recurrent funds for maintenance and operation offacilities and newly instituted programs, and take the necessay actions torectify any deficiencies.

I / The followidn calculation Is peovided for iofeortion only and aboe, the effects an project costestimates in Forint when applyiug the projected Iceal price escalation rates to both Local nad foreigncosts. The projected price escalation rates for goeds and *ervies are estimated at 19 percent in CY1992, 13 percent in 1993, 11 percent in 1994. 0 percent in 1995 and 7 percent thereafter.

Local erea"n Total--- Poriat lllian -------

Total Base Costs 2,486.9 5,e69.6 8,150.6Physical Contingencies 229.7 42.44 650.1Price Contingencies 3,7157 5578L7Total Proloct Cost 4,579.6 9.7S9.7 14,379.3

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B. Prolject Financing

3.4 The proposed Bank loan of US$91.0 million will finance 100 percent ofthe foreign exchange cost of the Project. The Government will finance thebalance of project costs (US$41.6 million) or 100 percent of local costs,including duties and taxes estimated at US$15.1 million equivalent. At theGovernment's request, retroactive financing of up to US$5.0 million will beincluded to cover the cost of equipment, specialist services and trainingnecessary for early project start-up (sub-components 1.11 and 2.31).Retroactive financing will be limited to expenditures incurred prior to loansigning but after July 10, 1992. The financing plan and financingrequirements by year are shown in Tables 3.3 and 3.4 below.

Tae 3.3: FINUICING PLAN

--1US$ Million--LocaL Forea Total

Xof Iof SofaMont Total Amont Total Amount Total

Governmnt of Sungar A 41.6 100l 0.0 O0 41.6 31SWorld uank 0.0 ,OX 1.0 nu M1A 15

Total Finsnin Reivremnts 41.6 100l 91.0 1001 132.6 1001

M/ tncludes financing of taxes and duties equivalent to US$15.1 millin.

Tmble 3 14 ANCIN REEQUIRUU BY YEA

Bank Fiscal Year 1993 1994 1995 1996 1987 1998 1999 2000 Total

Local Funds 0.7 3.8 7.3 9.6 5.6 5.2 4.6 4.6 41.6Foreign Funds i MLI is l . ..La LA _16

Total Financing 4.7 9.6 24.6 34.0 22.4 14.2 13.0 9.0 132.6

Iv 01 July 1092 - 30 June 1993.

C. ProJect Management and Iumlementation

3.5 Qvervniw. The Project will be implemented over a seven-year periodand is expected to be completed by December 31, 1999. The projectimplementation schedule is shown in detail in Annex 7. The Project will beiplememnted by the MOW, public health institutions, local government healthservices, medical universities, and the Central Statistical Office (CSO). ThecoordinatLon of all project-related activities will be the responsibility ofthe Project Management Unit (PMU) within the MOW. The project implementationresponsibilities are summarized in Chart 3.1 below, and described further inAmex 8.

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Chtll 3. 1: CHARST O PROJECT D4PLETITS1ON RESPoNsIBrLITIES

Subcomponent & Activity Responsible Line Implementing AgencyDepartment/Asency

Public Heslth Office of the CHO

Strengthening of NPHM Public Health Program UnitChronic Diseases Primary Prevention Nat'l Inst. of Health Prom.Chronic Diseases Secondary Prevention National Institute of OneologySchool Health NI8PHungarian Health Survey Central Statistical Office

Institutional Care MOW Departmentsresponsible for health

policy and medicalStroke Program technology Stroke programs in MOW/HPD

6 Recipient HospitalsCardiovascular Disease Hungarian Inst. Cardiology and

4 Recipient InstitutesPhysical Rehabilitation National Institute of Medical Rehab

Local Rehab. Centers

Public Health & ManaRement Trainint MOW Department ofEducation

School of Health Management Semelveis Medical Univ. and NPHCSchool of Public Health Seumelweis Medical University

Management Suv=ort System MCW InformationDepartment Health Information Center

MOW Computing Center SzekszardMIS Support for Hospitals Recipient Hospitals

Project Manaaement

Disbursements Project Management UnitProject Budget/Accounts MW PMUCoordination/Monitoring NOW PHUReporting PM/IUmplementing Agencies

Preinvestment Studies Policy Department Unit of the HOW

L Includes management of the COGP.

3.6 Proiect Management and Coordination. The PMJ, within the Ministry ofWelfare, will be responsible for coordinating the implementation of theProject. The PMW will facilitate resource flows to the implementing units,and to the extent appropriate, consolidate the procurement of goods andservices for greater efficiency and to achiene economies of scale. The PMUwill also serve as the clearing house for project issues requiring theattention of top MOW management and external agencies including the Bank. ThePHU will not design or implement programs and activities supported by theProject, as this will be the responsibility of existing MOW line departmentsand associate institutions. The PMU will: (a) facilitate the tasks to beundertaken by the various units/institutes preparing terms of reference(TORs), short lists, etc. for technical assistance (TA), fellowships, andtraining requirements for their employees, including higher level managers ofthe MOW; and it will participate in the technical evaluation of TA proposalsreceived, negotiations and award of contracts; (b) facilitate the tasks to beundertaken by the MOW's Health Policy Department (HPD) working with taskforces of clinical and equipment experts from MOW institutes/units in thepreparation of detailed lists, specifications and bidding documents for

- 27 -

medical and oth,er equipment, as well as participate in the technicalevaluation of bids; and (c) collaborate with the National Bank of Hungary(NBH) in processing disbursements and keeping track of project expenditures,funds and costs. The full-time Project Manager and two full-time seniorcoordinators have been appointed. The PNU's day to day operations will besupported by full-time technical staff (at least three positions) and supportpersonnel (at least two positions) with skills in accounting, procurement,contract administration, information processing, and records management. ThePMU'- responsibilities are described in further detail in Annex 8.

3.7 Given the Project's complexity and the need to support institutionalstrengthening in the MOW, the Project will provide technical assistance(111 staff-months) to the PMU and all implementing units in the areas ofproject management, planning, procurement and contract administration.Intensive support is planned (about 36 staff-months per year) during the firstthree years of implementation. This TA support for project management isexpected to taper off during the latter half of the implementation period toabout 1 to 3 staff-months per year by which time the PMU and HPD will haveacquired sufficient expertise. During negotiations, the TORs , as well as theprocedures for contracting the Project Management assistance to the PMU, werereviewed by the Bank and the MOW.

3.8 Project Iolementation Arrangements. In view of the limitedimplementation capability in some areas of project intervention, NOW will hireadditional professional staff to manage selected programs. The implementationof each project subcomponent will be the responsibility of the appropriate MOWdepartment or associate institution concerned, as shown in Chart 3.1 and Annex2. Each MOW department or associate institution will liaise closely with thePMU to ensure the timely flow of resources adequate for implementing itsprograms, and coordinate with other involved institutions. Procedures for theimplementation of each subcomponent are described in Annex 8. A ProjectOperational Manual (POM) is under preparation, describing for each component:(a) project action matrices; (b) detailed TORs for the necessary technicalassistance; (c) sample progress reporting and monitoring formats; and(d) technical background, as appropriate.

3.9 Bank Supervision. Although implementation responsibilities have beendefined in detail and TA will be provided in critical areas of management andimplementation, the Project will require, on average, about 25 staff-weeks ofBank supervision per year during the first two years of implementation, whenseveral policy-oriented components, tightly linked to the PAHIP (to bepresented to the Board at the same time as this project), will be implemented.These include payment of primary care providers, both private and public, aswell as the introduction of management support systems in hospitals and newpayment modalities for hospitals. Wherever possible, Bank staff will coverpreparation and multiple supervision tasks in the same missions for othersocial sector projects considered for Bank financing, including the PAHIP. Inaddition to Bank inputs, it is expected that supplementary resources financedby other international donors will also be involved to supervise ongoingparallel reforms that will strengthen social and community services, primarycare and the private health care sector. The project's supervision plan isshown in Annex-10.

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D. Project Procurement Arrangements

3.10 The procurement arrangements are summarized below:

Table 3.5: PRGCUREMENT ARRANGEMENTS A/(US$ Million)

Hot BankCategory of Expediture ICB LCB OTHiE Financed TOTAL I 1BRD

Civil works -- 6.0 -- -- 6.0(0.0) (0.0) oX

Purniture -- -- 2.2 -- 2.2-- (1.6)kf (1.6) 753

Equipnent/Computer Systems 37.4 -- 3.5 k -- 40.8(34.5) (3.3) (37.9) 931

Software/Books/Copyrights -- -- 3.6 I/ -- 3.6(3.4) (3.4) 931

lellowhips/Study Tours -- -- 5.5 l -- 5.5(5.5) (5.5) 1001

Specialists 11.8 af -- 11.8(11.8) (11.8) 0OO1

Training -- -- 1.5 9/ -- 1.5(1.5) (1.5) 1001

Studies/Program Development -- -- 29.4 j/ -- 29.4(29.4) (29.4) lO0

Incremental Salaries -- -- -- 4.6 V 4.6(0.0) O0

Dulding/Cemputer/Equip O& -- -- -- 10.8 V/ 10.8(0.0) OX

Computer Software Maintence -- -- -- 1.4 V 1.4(0.0) 0O

Non-salary Operational Costs -- -- 15.0 V 15.0(0.0) 0O

- - -- - - - -- - -- --- -- - -- - -- --- - -- -

Total Financing Requirements 37.4 6.0 57.4 31.9 132.6(34.5) (0.0) (56.4) (91.0) 69X

NIO: Numbers may not add up due to rounding.I/ Figures in parentheses are the respective amounts financed by the Bank Loan.bf International shopping (aggregate-US$3.9 million), packages estimated at less than US$300,000 each

contract; prudent local shopping/off-the-shelf purehases (aggregate-US$1.0 million) less thanVS$50.000 each contract.

g Intellectual property purchased directly/negotiated with publishers and/or copyright owners(Ahgregate-US3 .4 million).

IV Procurement according to Bank Guidelines for Use of Consultants.p/ Srvooes of consultants for preparation of studies engaged in accordance with Bank Guidelines for

Use of Consultants. Amount includes funds for Close the Gap Program (US$14.0 million base cost)a*uinistered following criteria approved by the Bank.

V Hiring of local staff and procurement of' non-salary items of recurrent expenditure financed byGovernment and ptocured in accordance with local procedures.

3.11 To the extent practicable, items to be procured will be grouped intomajor packages to encourage competitive bidding and permit bulk procurement.Procurement will be undertaken in the following manner:

v 29 -

(a) Procurement of Goods. Invitations to bid on equipment will begrouped by the PMU into major packages of goods, the contents ofwhich could be typically supplied by one supplier. Equipmentcontracts which are estimated to cost more than US$300,000 equivalentper contract will be procured following international competitivebidding (ICB) procedures in accordance with the Bank's "Guidelinesfor Procurement Under IBRD Loans and IDA Credits" (May 1992). Medicalequipment (about three major packages) will be packaged according torelated specialized fields. Computer hardware and peripherals (abouteig ht major packages) will be procured with careful consideration ofhardware compatibility and local availability of maintenanceservices. Equipment procured through ICB will account for about 80percent of the total value of equipment requirements. The remaining20 percent of the equipment value will be in packages suitable forprocurement other than ICB. In the comparison of bids for equipmentto be procured through ICB, domestic manufacturers will be allowed apreferential margin of 15 percent, or the existing customs duty,whichever is lower, over the cost, insurance and freight (CIF) pricesof competing imports.

(b) The exceptions to ICB procurement will be:

(i) Local Competitive Bidding (LCB). The LCB procedures agreedwith NBH for procurement under the Product Market DevelopmentProject (Loan 3509-HUW) will also apply for LCB procurementunder this project. A standard LCB bidding document for civilworks has been approved by the Bank for use under the ProductMarket Development Project. The refurbishing/remodelling ofbuildings (US$6.0 million equivalent) which will be entirelyfinanced by the Government will be procured on the basis oflocal competitive bidding procedures acceptable to the Bank.

(it) International Sho=invf (IS). IS procedures will be used forsmall amounts of equipment where the cost of ICB will clearlyoutweigh possible price advantages. Contracts for equipmentestimated to cost less than US$300,000 per contract, not toexceed an aggregate amount of US$3.9 million equivalent, willbe awarded under international shopping procedures, based oncomparing price quotations obtained from at least threesuppliers from two countries eligible under the Guidelines inaccordance with procedures acceptable to the Bank.

(iii) Local Shogping (LS). Minor sundry items not exceedingUS$50,000 per contract, up to an aggregate amount ofUS$1.0 million equivalent, could be purchased on the basis ofprudent local shopping by comparing price quotations obtainedfrom at least three local suppliers, in accordance withprocedures acceptable to the Bank.

(iv) Direct Prourement. Goods and technical licenses which theBank agrees: (a) are of proprietary nature; (b) the timelysupply thereof is critical for efficient project execution; or

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(c) need to be compatible with other installed equipment, maybe procured through direct negotiations withproperty/copyright owners, on terms and conditions acceptableto the Bank. Such items include contracts for intellectualproperty such as books, technical journals, trainingmaterials, audio-visual materials, computer applicationssoftware, including annual upgrading and licensingarrangements, copyrights, translation and reprinting rightsfor training materials, estimated to cost about US$3.4 millionin the aggregate.

(v) Technical Assistance. Qualified firms will be invited tosubmit proposals for comprehensive packages of consultantservices and management of fellowships and training inaccordance with the "Guidelines for the Use of Consultants byWorld Bank Borrowers and by The World Bank as ExecutingAgency" (August 1981). To keep the evaluation processmanageable, no more than six (but at least three) proposalswill be invited following a short listing acceptable to theBank. As needed, the services of individual specialists(mainly to develop computer applications software) will alsobe contracted on the basis of short-lists of eligiblecandidates. All technical assistance services will beprocured in keeping with the terms of reference for suchservices described in the PO and in keeping with the TApackages and schedule set out in Annex 11. Implementing unitswill be provided with adequate technical support to manage theselection process (para 3.7).

(vi) Studies/Close the Gap Pr tram (CGP). The Project will providefunds (US$14.0 million base cost) under the CGP for thepiloting/implementation of innovative health promotionprograms proposed by communities and schools/institutions.These programs will be selected on a competitive basisfollowing criteria described in Annex 2. The Project willalso fund (US$15.4 million aggregate) the preparation ofselected studies/research/surveys related to the developmentof the health sector in Hungary. Awards of contracts toinstitutions/specialists for these studies will be in keepingwith the provisions of the Bank Guidelines for the Selectionof Consultants.

(vii) Incremental Recurrent Costs. Building and equipmentmaintenance services, annual maintenance costs of computersoftware, staff salaries and other non-salary operationalcosts (US$31.8 million equivalent) will be financed entirelyby the Government. These items will be procured in accordancewith standard Government procedures which are acceptable tothe Bank.

3.12 Contract Review. All equipment listed in sub-components 1.11 and2.31 in Annex 6, with an aggregate amount of US$5 million to be financed

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retroactively, will be procured following ICB procedures in accordance withBank Guidelines. TA contracts, including training and fellowships insubcomponents 1.11 and 2.31, to be financed retroactively, are required forloan effectiveness (paras 2.19 and 5.3), and will be awarded in accordancewith Bank Guidelines for the Use of Consultants. Model bidding documents forICB and TA procurement have been prepared for Hungary with Bank assistance,and are available at the NBH. However, the World Bank will continue to reviewmaster lists of equipment, packaging of bids and updated cost estimates. Withrespect to each contract for goods estimated to cost the equivalent ofUS$500,000 or more, provided, that with respect to the first contracts undereach subcomponent estimated to cost the equivalent of US$300,000 or more andall the contracts under the CGP (Part l,a(ii) of the Project) estimated tocost US$300,000 or more, the procedures set forth in paragraphs 2 and 4 ofAppendix 1 of the Guidelines shall apply. It is estimated that this priorreview will cnver about 80 percent of the value of all contracts combined forequipment and technical assistance. The remaining 20 percent of contractswill be subject to selective post award reviews by the Bank. The Bank willreview only TORs and short lists for consultant contracts under US$100,000equivalent; above this threshold standard, World Bank review procedures willapply.

3.13 Disbursements. The proposed project is expected to be disbursed overa period of about seven and one-half years, or about one and one-half yearsshorter than the average disbursement profile (eight and one-half to nineyears) for health sector projects financed by the Bank. The closing date willbe June 30, 2000. The disbursement period is expected to be met as the majorproject expenditures for medical equipment and computer hardware are scheduledto be incurred and completed during years two through four of theimplementation period. The detailed disbursement schedule is shown in Annex. The financing plan by disbursement category is shown in Table 3.6 below.

Table 3.6: FINANCING PLAN BY DISBURSEMENT CATEGORY(US$ Million)

Government of TotalW"orld Bank uSUGARY Financing

Category of Expenditure Amount I Amount S Amount 2 of Total

TDCAL U 48.1 1002 0.0 0 e 36XLocal Training 1.5 1OOX 0.0 O0 1.5 1SPeflowahips 5.5 1OOX 0.0 OX 5.5 41Specialists 11.8 1002 0.0 0 11.8 9XStudies/Program Development q/ 29.4 1002 0.0 02 29.4 222

MWUJIIM POURUITORK and S".IIAU 4 937 46.7 35XEquipment/Computer Systems 37.9 931 2.9 71 40.8 311Software/Books/Instructnl Matls 3.4 932 0.3 72 3,6 32Furniture 1.6 752 0.5 252 2.2 22

CIVIL lowX 0 0 OX 6 100 lOO 80 5SConstruction/Upgrading 0.0 ox 6.0 100l 6.0 52

nYErX30fa BECURRgN COST 0A 0 1 OX 1 100X 31.9 24XLocal Staff Salaries 0.0 OX 4.6 1002 4.6 32Building/Equip/Computer 0M 0.0 OX 10.8 1002 10.8 8XComputer Software Maintenance 0.0 OX 1.4 1002 1.4 1XSon-salary Operational Coats _0A 0 j _O 5l 0 lOO 15,0 llX

TOTAL FIAEfIAB 91.0 69X 41.6 312 132.6 1002

NOTE: Numbers may not add up due to rounding.f/ Includes funds (US$14.0 million base cost) for the Close the Gap Program.

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3.14 Disbursements will be made as follows:

(a) 100 percent of foreign expenditures for goods, including equipment,furniture, books, training materials, software, supplies andmaterials; 100 percent of ex-factory cost of locally manufactureditems; and 75 percent of the cost of goods procured locally;

(b) 100 percent of expenditures for technical assistance, fellowships,training and preparation of studies/research; and

(c) Close the Gap Program:

(i) 100 percent of foreign expenditures for goods, 100 percent oflocal expenditures (ex-factory cost) and 75 percent of localexpenditures for other items provided locally; and

(ii) 100 percent for consultants services, training andfellowships.

3.15 All disbursements will be fully documented except for contractscosting less than US$300,000 equivalent. For expenditures below that level,disbursements could be made on the basis of Statements of Expenditure (SOB)certified by the PMU Project Manager. Records maintained separately by thePHPU and PMU for the CGP will be supported by contracts between MOW and theimplementing body, describing the scope of the programs/activities and theschedule of fund releases linked to monitorable performance indicators. Therequired supporting documentation will be retained by the PMU for at least oneyear after receipt by the Bank of the audit report for the year in which thelast disbursement was made. This documentation will be made available forreview by the auditors and by visiting Bank staff upon request.

3.16 Sgecial Account. To facilitate timely project implementation, theGovernment will establish, maintain and operate, under terms and conditionsacceptable to the Bank, a Special Account denominated in US Dollars in theNational Bank of Hungary, into which the World Bank will deposit an initialamount of US$4.0 million, which is judged adequate to cover about four monthsof foreign expenditures under the Project. The Special Account will bereplenished as appropriate when the undisbursed balance of the Account fallsbelow an amount equal to 50 percent or less of the amount of the SpecialAccount. Documentation requirements for replenishment applications willfollow the same procedure as described in paragraph 3.15. In addition,monthly bank statements of the Special wecount which have been reconciled bythe Borrower will accompany all replen. went requests. A Project Account inForints will be established prior to Loan Effectiveness which will be used bythe PMU for expenditures to be covered by local counterpart financing.

3.17 Project Accounts and Audits. Separate project accounts (includingone for the CGP), will be maintained by the PMU for the Project. Projectaccounts (including CGP accounts) and the Special Account, will be audited inaccordance with the Bank "Guidelines for Financial Reporting and Auditing ofProjects Financed by the World Bank* (March 1982). The Borrower would providethe Bank (within six months of the end of each fiscal year), an audit report

- 33 -

of such scope and detail as the Bank may reasonably request, including aseparate opinion by an independent auditor acceptable to the Bank, ondistursements against certified SOEs. The separate opinion should mentionwhether the SOEs submitted during the fiscal year, together with theprocedures and internal controls involved in their preparation, can be reliedupon to support the related withdrawal applications.

E. Proiect Regorting and Evaluation

3.18 Reporting and Annual Reviews. The PMU will prepare semi-annualdescriptive and financial reports on each project component, objective andactivity (beginning from the date of Loan Effectiveness). The reports willdescribe: (a) current status; (b) deviations, if any, from the implementationplan set forth in Annex 7; and (c) the reasons for deviations and correctiveactions being taken. Sample progress-reporting documents are included in thePOX. Reporting and Bank supervision will focus on in-depth reviews of thepolicy framework for sectoral improvements, the consistency of activities foreach component and subcomponent with agreements reached at negotiations,performance of the implementing groups and institutions, assessment ofemerging needs for adjustments to project parameters, and possible follow-upoperations which could be supported by the Bank. Bank supervision will bebased on the semi-annual progress reports and the annual evaluation of projectactivities by the MOW. This will be supplemented by a review of projectexpenditures and availability of financial resources, in addition tosubstantive discussions with technical assistance groups implementing and/orassisting in the implementation of various components, and discussions withresponsible authorities. The POM, agreed upon with the Government duringnegotiations, will also be used to assist supervision and reporting. Duringnegotiations, assurances were obtained that, not later than March 31 of eachyear during the execution of the Project, the Borrower shall furnish to theBank a technical and financial report, of such coverage, detail, and format asthe Bank may reasonably request, on the status of Project implementation (asof December 31 of each year) and review, thereafter with the Bank issuesrelated to the execution of the Project.

F. Status of Preparation

3.19 Proiect PreDaration. The status of preparatory activities at thetime of Negotiations in January 1993 was as follows:

(a) Designation of Project Coordination and ImpleMentationResponsibilities. Implementation and coordination responsibilitiesof the PKU and MOW institutional units have been defined. Theprincipal officers of the PMU are in place and the support staff willbe recruited. The Coordinator of the PHPU has been appointed. Teamleaders who had participated in project preparation have been

- 34 -

retained for the implementation of the Project component/subcomponenteach has prepared.

(b) EguFpint L:ists/Bidding _gocumentA. There are existing standard draftbidding documents for works, equipment and services prepared by theNBH with Bank assistance for use in Bank-financed projects inHungary. These standard bidding documents will be modified by thePMU/HPD to suit the specific requirements of the Project. Equipmentmaster lists have been prepared but technical specifications need tobe further detailed. An equipment specialist will be contractedshortly to help finalize this documentation.

(c) Project Management Assistance. The Borrower has prepared a shortlist of firms to provide project management assistance. TORs forthis TA have been prepared and are included in the POM.

- 35 -

IV. BENEFITS AND RISKS

A. Benefits

4.1 The Project's ultimate benefit will be improved health achievedwithin an environment of tight constraints on public expenditures. Mortalityand morbidity will be reduced over the long term following the implementationof a national strategy to decrease smoking, alcohol consumption and unhealthydiets, and following the improvement of a clinical response capability torelated diseases. The quality and cost effectiveness of health care will beenhanced through the switch in focus from curative hospital care to preventivemedicine and primary care. A new and more effective balance in thepublic/private mix will allow the public sector to focus on specific areas ofclear-cut market failure. Further gains in efficiency and more effective carewill result from the improved professional training and better health servicesmanagement techniques introduced through the Project. These measures willcontribute to expenditure control in the health sector and have importantcross-benefits for the companion PAHIP.

B. Risks

4.2 The Project's major risks include: (a) the weak institutionalcapacity of the MOW to implement major reforms; (b) the need to create newadministrative structures such as the planned new School of Public Health andSchool of Health Services Management; and (c) the loss of expenditure controldue to the introduction of performance-related reimbursements for health careproviders which could jeopardize the financial viability of the HIF. SpecificProject interventions have been designed to contain these risks. The Schoolsof Public Health and Health Services Management will address the weakinstitutional capacity of the health sector by providing training andfellowships in policy-making, management and evaluation. Extensive twinningarrangements with similar institutions in western countries and technicalassistance will reduce the risk of establishing new administrative structures.Management consultants will be hired to strengthen project management and toenhance project implementation. Finally, policies will be introduced tocontain health care expenditure and prevent a cost explosion. The Bank willconduct a mid-term review of these policies to ensure that they will have beeneffective and that they will not have had adverse spill-over effects on thestate budget.

- 36 -

V. AGREEMENTS REACHED AND RECOMMENDATION

5.1 The following actions are required to assure successfulimplementation of the Project and attainment of the broader projectobjectives.

5.2 During negotiations, assurances were obtained that:

(a) for the purposes of cost-containment and to protect the financialviability of the HIF, the Borrower shall take all necessary measuresthrough budget caps and other expenditure controls, to ensure thatthe aggregate of all expenditures on health services financed throughHIF for a given year, including performance-related reimbursementsfor doctors, hospitals and other health care providers, would notexceed the health services budget of HIP for that year (total HIFbudget net of cash benefits financed through health insurance) (para.2.3);

(b) not later than June 1, 1993, a new Public Health Program Unit (PHPU)shall be established in the Office of the Chief Medical Officer (CMO)and shall be maintained to manage the Public Health subcomponent ofthe Project. The PHPU shall be staffed with a full-time director andproject manager, whose experience and qualifications shall beacceptable to the Bank and who shall be assisted by competent staffin adequate numbers. The PHPU shall liaise with the PMU andcollaborate with other implementing agencies (para. 2.5);

(c) the Borrower shall apply the criteria, guidelines and procedures forawards of grants under the CGP agreed upon with the Bank, and futurechanges to, or introduction of, new criteria, guidelines andprocedures shall be subject to Bank approval prior to theirintroduction and implementation (para. 2.8);

(d) during execution of the Project the Borrower shall maintain withinthe MOW the Project Management Unit (PHU) to be headed by a full-timeproject manager, whose experience and qualifications shall beacceptable to the Bank, and who shall be assisted by competent staffin adequate numbers (para. 2.19); and

(e) not later than March 31 of each year during the execution of theProject, the Borrower shall furnish to the Bank a technical andfinancial report, of such coverage, detail, and format as the Bankmay reasonably request, on the status of Project implementation (asof December 31 of each year) and review, thereafter with the Bankissues related to the execution of the Project (para. 3.18).

5.3 Condition of Loan Effectiveness. For loan effectiveness, the Bankwill require that the MOW has signed a contract to employ a managementconsultant firm to strengthen the PMU's project management capacity (para.2.19).

- 37 -

5.4 Condition of MiaburseMents. No withdrawal shall be made in respectof payments made for expenditures under Category (3) (Schedule 1 of the LoanAgreement) unless Hungarian and international members for the Close the GapCommittee for the CGP have been selected on the basis of criteria satisfactoryto the Bank, and the first committoe meeting has been hold (para. 2.8).

RLecommendati

5.5 Subject to the above, the proposed operation provides a suitablebasis for a loan of US$9l.O million to the Government of Hungary.

- 39 - AEX 1

REPUBLIC OFHUNGARY

WALTH SUERVICES AND NANAGEMENT PROJECT

PUBLIC HEALTH AMD DISESSE PREVENTION SUMCOMPONENT

A. E ISSUES

Life Exoectancy

1. The health status of Hungary is the worst of any country in Europe.It has declined relative to Western Europe since the 1950s, and in somerespects, has declined in absolute terms over the past two or three decades.This is, perhaps, surprising in view of the fact that certain other Easternand Central European countries are poorer, and national wealth or GDP percapita is generally recognized as one of the key determinants of healthstatus.

2. Hungary is typical among Central and Eastern European countries withrespect to the evolution of its health status since World War II. In the late1940s it had a health status very similar to Austria and other WesternEuropean countries. Since then, communicable diseases, infant mortality,maternal mortality and occupational diseases have been reduced verysubstantially, but not to the same extent as in its western neighbors. Bothnon-communicable diseases of adults, and injuries, have increased recently.They are now the major cause of the large disparity with western countries inadult mortality and overall life expectancy.

3. Infant mortality rates have fallen from 86 per 1,000 live births in1950 to 15 in 1990, but still remain around double the Western Europeanaverage. Despite improved infant mortality, life expectancy at birth formales and females was only 65.1 years and 73.7 years, respectively, in 1990.For comparison, life expectancy at birth in Western Europe is around 71 yearsfor males and 77 years for females. Over the past two decades life expectancyat birth for males has fallen by 0.9 years and life expectancy at age 30 formales has fallen by 4.2 years. Life expectancy for Hungarian females has beenunchanged over the same period, while Western European countries havewitnessed substantial increases in life expectancy for women.

4. The major causes of poor life expectancy and the "mortality gap"between Hungary and Western Europe is mortality rates from certain non-communicable diseases in adulthood, especially: cardiovascular diseases,cancers and injuries. Age-standardized death rates for men aged 30-69 yearsrose between 1970 and 1985 by over 30 percent for all causes and by about 30percent for cardiovascular causes. The equivalent figures for women wererises of about nine and five percent, respectively. The major causes, indescending order of importance, of mortality and years of healthy years of

- 40 - ANMX

life lost in males aged 15-64 years are cardiovascular disease (of which acutemyocardial infOarction is the largest cause), cancers (of which lung cancer Isthe largest cause), and injuries (of which suicide is the largest cause).Other causes for which mortality rates In adults in Hungary are strikinglyhigher than in other European countries include chronic respiratory disease,tuberculosis, appendicitis and liver cirrhoses. This disparity in adulthealth between Hungary and Westera Europe is illustrated in Table 1 bycomparison with recent mortality rates in Austria, and in Table 2 bycomparison with 20-year time trends in England and West Germany.

5. Risk factors for chronic diseases are consistent with these patternsof high mortality risks. About 50 percent of Hungarian adults smoke, obesityis common, hypertension is poorly controlled, over 40 percent of dietaryintake in calories comes from fat, and sedentary lifestyle is common. Thereare currently no effective public health programs to address these chronicdisease risk factors, and there are not any national policies to address theneeds for tobacco control and improved nutrition.

Table 1.Risk of death (X) between 15 and 60 years

of age for males and femalesin Hungary and Austria

meles FemalesCause of -----------------------------------death

Hungary Austria Hungary Austria

Communicableand reproductive 0.5 0.3 0.2 0.1

Noncommunicable 21.2 11.8 10.8 6.3of which:cancers 6.6 4.2 4.3 3.3cardiovascular 9.4 4.7 3.9 1.7

Injuries 6.3 4.7 1.8 1.2of which:suicide 3.1 1.9 1.0 0.6

All causes 28.1 16.8 12.8 7.6

Source: Feachem et al. (1992). IEa Hh4lth of AdUlts in the DevelopingWorld. New York: Oxford University Press.

- 41- ANNEX 1

Table 2..Percent change in Mortality (1970-1987)*

Total Mortality(1987) Total IHD* Stroke Cervical

Cancer

England 876 -18 -15 -41 -18W.Germany 849 -25 -13 -40 -50Hungary 1262 +3 +42 +37 +12

Source: Boys, R.J., Forster, D.P., and J6zan, P. (1991). Mortality from

causes amendable and non-amendable to medical care: The experience of

Eastern Europe. British Medical Journal, 303:879-883.*IHD - Ischemic Heart Disease.

Public Health Service

6. On March 20, 1991, the Hungarian Parliament passed Law No XI on the

"State Public Health and Medical Officer Service." The details of the

organization and operation of the new public health service were laid down in

Decree No 7/1991 of the Ministry of Welfare (MOW). Law XI of 1991 and Decree

7/1991 reorganized the preexisting network of public health institutions intoa hierarchical system under the control of the MOW, substantially increasing

the competencies and responsibilities of these institutions.

7. The new public health service is headed by a Chief Medical Officer

(CMO), who is also Director of a new National Public Health Center (NPHC).

The CMO is supported by 20 county Medical Officers (MOs), who are Directors of

the county Institutes of Public Health (IPH), and 146 local Mos, who are

Directors of the local IPH. The 166 new MOs were appointed in late 1991.

8. The new public health system has three levels: the NPHC, consisting

of seven pre-existing national institutes; an intermediate level, consisting

of 20 county level institutes (including one large institute for Budapest);

and 146 municipal (town, city or, in Budapest only, district) level

institutes. The mean population served by a municipal IPH is 73,000, although

the distribution is heavily skewed with many serving much smaller populations.

Typically, a municipal institute will have 10-15 staff including one or two

public health doctors. County-level institutes (with the exception of

Budapest) serve a mean population of 460,000 people and have a total staff of

150 to 180.

9. The new IPHs are similar to the Sanitary and Epidemic Prevention

Systems (SANEPID) found in other Central and Eastern European countries. They

are essentially a reorganization of the SANEPID Public Health Systems that

were created after World War II based on the Soviet model of public health

services. The former system was administered by local councils ('elected'

- 42 - ANNEX I

from candidates appointed by the communist party) and their roles were relatedmainly to environmental health, and included monitoring infectious diseases,food hygiene, and air and water quality. In addition, they providedmicrobiology laboratories for the hospital service and a limited healtheducation service.

10. The seven pre-existing institutes that are now incorporated into theNPHC are:

National Institute of Hygiene (NIH);National Institute of Occupational Health and Medicine (NIOHM);National Institution of Radiation Biology and Health (NIRBH);National Institute of Nutrition (NIN);National Institute of Health Promotion (NIHP);National Institute of Dermatology and Venereal Disease (NIDVD); andNational Institute of Pharmacy (NIP).

Table 3: STAFFING OF THE NATIONAL PUBLIC HEALTH CENTER, 1991

Institution Doctors Graduates Specialists Te1hnical/ Manual Total*dmin

Instituteof Hygiene 85 98 235 122 228 768

Institute ofOccupationalHealth 120 49 178 42 47 436

Institute ofRadiation 22 52 92 33 72 271

Institute ofNutrition 15 34 60 15 18 142

Inst of HealthPromotion 6 20 28 24 9 87

Institute ofPharmacy 2 87 33 28 17 167

Office ofthe CMO 17 3 3 12 2 37

20 county & 146local IPH 908 358 3502 860 912 6540

TOTAL 1175 701 4131 1136 1305 8448

- 43 - ANNEX

11. Table 3 above shows the staffing pattern of the NPHC and Table 4below shows expenditures for 1991. The NPHC is provided with a global budgetby the NOW. The CMO allocates this budget amou-tg dte seven nationalinstitutes, the CMO's Office and the 166 IPHs. In 1992, a budget increase often percent was provided for salaries and a five percent increase for othercosts. With inflation anticipated at around 25 percent for 1992, thistranslates into a significant real expenditure cut on public health servicesfor this year. In the near future, "task financing" may be introduced for theNPHC under which individual institutions will receive a budget based on anagreement to carry out specific functions or activities.

Table 4: EXPENDITURE OF THE NATIONAL PUBLIC HEALTH CENTER, 1991(Ft million)

Institution Salaries Social Security Non-Salaries Total

Institute ofHygiene 201 77 331 609

Institute ofOccupationalHealth 110 43 32 185

Institute ofRadiation 68 26 76 170

Institute ofNutrition 48 19 31 98

Institute ofHealthPromotion 34 13 61 108

Institute ofPharmacy 38 15 35 88

Office ofthe CMO 23 10 18 51

20 County and146 local Inst ofPublic Health 1909 743 968 3620

TOTAL 2431 946 1552 4929

- 44 - ANNEX 1

12. Previous and current activities of the seven national institutes andthe 166 sanitary and epldemiology stations have not been fundamentallyquestioned or reviewed since establishment of the NPHC. The seven nationalinstitutes carry out activities, including service and research, in the areaof responsibility suggested by their name. Some are engaged in activitiesthat no longer serve a mandated purpose while others are engaged in activitiesthat would be better conducted elsewhere. Many of their senior staff alsohave academic appointments at the Postgraduate Medical University (inBudapest) and conduct postgraduate teaching.

13. Activities which serve no discernible purpose include much of theenvironmental monitoring that is carried out. For example, air quality ismonitored at 20 sites in Hajdd-Bihar County and the data are compiled locallyand sent to the National Institute of Hygiene to form part of the nationalrecord. Although large volumes of data are collected in this way, there is noapparent link between this data collection and any policy or action to improveair quality. There also appears to be no strategic thinking concerningexactly what types of air pollution should be reduced nor how that should beaccomplished. The meteorological services and the Ministry of Environmentalso, quite separately, collect air quality data.

14. Current activities of the IPHs that would be better done elsewhereinclude much of their clinical laboratory work. IPHs at county levels carryout most of the clinical bacteriology (including all the entericbacteriology), all the clinical virology and mycology, and most of theclinical immunology for local hospitals. Even the major teaching hospitals donot carry out these diagnostic tests themselves. It would be preferable tostrengthen hospital laboratories to conduct these tests and removeresponsibility for routine clinical microbiology and immunology from IPH.This would eventually improve patient care while freeing up capacity in theIPHs. Reference laboratories could be provided at the NPHC or at majorhospitals.

15. The new NPHC is currently not optimally organized to carry out itsmandate. Restructuring and reorganization of the NPHC is urgently needed,starting with a redefinition of its mission and main functions. Under Law NoXI of 1991, the new tasks and responsibilities which the NPHC must addressinclude the following:

* public health and public health policy throughout Hungary except forthe armed forces;

* monitoring and evaluating the health status of the population and allfactors influencing the health status;

* health education and public awareness;* setting standards, monitoring and enforcing public health and

environmental standards, including standards for the air, water,waste, soil, food, the workplace, and toxic substances;

* nutrition and nutrition policy;* public health standards in schools, hospitals and other institutions;* infectious disease control;

- 45- ANNEX

* vaccination programs;* supervision of primary care services, family health services,

maternal and child services, school health services, mental healthservices, occupational health services, sports health services;

* advice on any matters affecting the health services;* supervision of pharmaceutical supplies;* approval of technical specifications for buildings, and town and

regional plans; and* authorization of production, storage, transport and use, and any new

materials or articles for direct use by the general public.

16. Recent changes in the mandate of the public health service can beillustrated by describing recent changes in the organizational structure oftwo county health agencies. The Institute of Public Health for Haidu-Biharcounty, within which Debrecen is located, is one example. The formerdivisions and branches which were designed to address environmental andinfectious disease public hygiene problems have now been reorganized toinclude responsibility for health problems that will be addressed by the newmission of the public health service. A Health Protection Branch has beenadded to the agency. There is a department for health education whichincludes mental hygiene, prevention, as well as curative and preventiveservices. There is also a department for supervising family, maternal andchild, youth, and occupational health services. Similarly, in Baranya countywithin which Pdcs is located, the Institute of Public Health was recentlyreorganized. That reorganization included creation of a new unit for healtheducation and health promotion which will be responsible for improving healtheducation of children as well as general health education of the adultpopulation and chronic disease prevention.

17. As another example, the National Institute of Hygiene was created in1927 with the support of the Rockefeller Foundation. The CNO plans to splitthis institution into an Institute for Epidemiology, modeled on the Center forDisease Control (CDC, Atlanta, USA), and an Institute for EnvironmentalHygiene. This would allow for the development of more concerted objectives inchronic disease prevention within the Institute for Epidemiology.

Information on Health Status

18. Large amounts of data on public health were collected over the pastforty years, yet there has been little critical analysis and few connectionshave been made with public health policy. Data have long existed that showthe growing gap in health status between Hungary and Western Europe. Thisinformation was not made readily available to the public, and the Governmenttook no explicit action to address the problem.

19. Splintering of data sources and poor communication links is animportant part of the problem. The National Statistics Office (NSO) has aDepartment of Population and Health Statistics which is responsible for thecollection and analysis of data on births, deaths, abortions, and statisticsrelating to the activities of the health services. Census data are the

- 46 - ANNEX I

responsibility of a separate census bureau which provides its data to the NSO.Death records go back over 100 years but the reliability of the information inthese records is suspect. Death certificates are completed by pathologists orclinicians, while separate death data sheets are completed by civilregistries. Although the latter data sheet contains information on the age,sex, address, marital status, education, fertility, employment and occupationof the deceased, postal codes are not recorded. A district within a city is,therefore, the smallest geographical area for which death rates can becomputed, the numerator data being the limiting factor.

20. There is a weak link between the data collection and analysisconducted by the NSO and clinical activities of the MOW and local governments.Hungary lacks an adequate national cancer registry system, and there is a needfor improved data management and communications within the NPHC as well asbetween the NPHC and other sectors. Three cancer registries exist, onenational and two regional. The national cancer register is located at theInstitute of Oncology in Budapest. It collects data of limited accuracy andcompleteness for the whole country. More complete and accurate data for thecounty of Vas is collected at the registry at Szombathely and for the countyof Szaboles-SzatmAr-Bereg at the registry at Nyiregyhaza.

21. The capacity to conduct applied research and evaluation research onpublic health problems and programs is limited. This should be strengthenedin the future to develop action-oriented public health programs.

22. Even when data is collected on a regular basis, passive reportingleads to considerable under-reporting and low-quality of information. Forexample, the IPHs collect a variety of data on communicable diseases,vaccinations, health service activities, environmental risk factors,occupational diseases and food poisonings. They report this data to theappropriate national institute, but regular timely reporting back to the fieldis rare. With no feedback, the IPHs are not motivated to improve theirreporting.

23. Finally, there is currently no system for conducting surveillance onrisk factors for chronic disease. There is a ,'articular need for this type ofsurvey given the high rates of chronic diseases which could be prevented bychanges in health-related behavior in the population. The high prevalence ofsmoking and poor diet have been estimated by spot surveys in recent years, butthese surveys were often based on poor sampling methods and/or had littlequality control in the data collection and analysis phases.

Health Promotion and Disease Prevention ProgramLs

24. The high, and increasing rates of cerebro/cardiovascular disease canbe viewed as an indication of ineffective clinical management of hypertension.General practitioners have not been well trained, or adequately reimbursed forproviding basic clinical preventive services, including the management ofhypertension. One of the first priorities of primary care medicine is theimmediate improvement in the detection and in the management of hypertension

- 47 . ANNEX I

so as to reverse the increasing rates of stroke and ischemic heart disease.

25. Another telltale marker of inadequate clinical preventive services isthe increasing rate of cervical cancer mortality. This increasing mortalityis occurring at the same time that the number of Pap smears, an effectivescreening procedure for early cervical cancer detection, is decreasing. Goodcytological laboratories already exist so another high priority for retrainingin primary care medicine is, therefore, in gynecologic exams and in performingPap smears.

26. There is also a need for a public policy on tobacco to help to reducethe current high rates of tobacco consumption. Presently, there are virtuallyno organized activities for smoking cessation, despite the fact that over 50percent of Hungarian adults smoke and over 50 percent of doctors are smokersthemselves.

27. A closer working relationship in the future between the Public HealthService and primary care doctors will be essential to improving control ofhypertension, smoking, and cancer.

Research Grants

28. There is an urgent need to stimulate innovative applied research inpublic health and epidemiology so as to control cardiovascular disease, cancerand injuries. This might be done through the training of a new generation ofresearchers and the establishment of a more substantial and incentive drivenfinancing mechanism for research in these areas. Establishing such amechanism within the NPHC would strengthen research in public health andfacilitate the needed reorganization of public health institutions in aconstructive way.

29. Presently there are no foreign reviewers or advisors to bring aninternational perspective to research financing. Medical research is theresponsibility of national institutes under the MOW, Medical Universities,individual hospitals, and the Institute of Experimental Medical Science of theHungarian Academy of Science. Most research is financed through the regularrecurrent budget of these organizations, rather than through a competitiveprocess with peer-review for limited funding.

30. The creation of a Medical Research Council (MRC) by the MOW was asmall step forward. The MRC is controlled by a Board comprised of independentscientists. The Secretary, a biochemist, works part time at the Ministry onsecondment from his substantive post at the Semmelweis Medical University.Twelve committees disburse funds for particular programs and projects. Thechairman of each of these committees also sits on the MRC Board. Thecommittees relevant to public health are those on Environmental Health,Epidemiology, and Social Medicine. In addition, the central governmentadministers a Scientific Research Fund of which about Ft 120 million per year(approximately US$1.6 million) is spent on medical research. The emphasis for

- 48 - ANNEX X

this Fund in on basic research of international quality using internationalreferees.

31. Unfortunately, the NRC is presently distributing limited financialresources in such a way as to keep alive most or all research groups acrossthe whole system in the hope that increased resources will become available inthe near future. This has led to underfinancing of institutions that have thecapacity to conduct good research and waste resources on institutions that nolonger serve a useful function. The MRC is allocated an annual budget by theMOW. In 1991 the budget was Ft 90 million (approximately US$1.2 million).The 1992 budget fell by approximately 20 percent in real terms. Approximately70 percent of the budget is allocated to research at the Medical Universities,20 percent to national institutes and 10 percent to individual hospitals.Funds allocated by the MRC cannot be spent on salaries, which is theresponsibility of the concerned institutions. Grants have a maximum cap of Ft800,000 per year for three years (approximately US$10,500).

32. No longitudinal studies have ever been conducted in Hungary todemonstrate the relationship between hypertension, obesity, smoking, and highcholesterol as related to chronic disease risk. Experience from westerncountries indicates that it is useful for an individual country to demonstratethe importance of its own chronic disease risk factors. The type of researchthat is acutely needed is high quality applied/evaluation research in chronicdisease prevention. This could include survey research on chronic diseaserisk factors and on the performance of programs designed to reduce chronicdisease risk through either primary or secondary prevention efforts.Excellent candidates for research in this area would be an evaluation ofprograms designed to reduce tobacco use, improve diet, improve hypertensioncontrol, and decrease sedentary life style in well-defined populations orcommunities. This type of research is crucial to the success of chronicdisease prevention programs, as it can discern which approaches are successfuland which are not, and thereby help to improve the efficiency of the scarcehuman and financial resources.

B. STRATEGIES FOR REFORM

Objectives

33. Significant reform of the Hungarian public health service is acritical prerequisite to improving the bleak health status of the populationand to begin *closing the health and mortality gap" between Hungary and itswestern neighbors.

- 49 - ANNEX 1

34. The specific objectives of the Project in this respect are four-fold:

(a) To strengthen the NPHC by creating a high-level policy and leadershipunit to support a new public health agenda in the country. Althoughthe unit may make use of some existing institutions and programs whendeemed appropriate, a special effort would be made to maintain theunit's independence so as not to reinforce ineffective parts of theold system.

(b) To strengthen information available to public health policy makersand to the public at large on health status and risk factors. Theinformation base for public health decision making would be enhancedthrough applied research, surveys, routine data collection andimproved communication systems.

(c) To launch priority public health programs immediately. This includesactivities in the fields of primary prevention, secondary preventionand school health. An element of trial and demonstration would bebuilt into many of these activities to allow lessons to be learnedand experience to be gained prior to scaling up to the nationallevel.

(d) To make provision for future public health initiatives which cannotbe launched immediately. Some public health initiatives which may bedesirable in the future cannot be launched immediately because ofuncertainty about the preferred approaches and the lack of thenecessary social/political consensus. An example would be measuresto reduce the high rate of alcoholism, suicide and non-intentionalinjuries or strong measures against tobacco abuse (including massivetax increases and a complete ban on advertising).

C. DETAILED SUBCOMPONENT DESCRIPTION

Strengthening Public Health Policy and Action

35. SRecific Background. The highest priority of the health sector is tobegin to close the gap in health status between Hungary and Western Europe.In designing the reforms of the Hungarian health care system, this ultimateobjective must be kept constantly in view. If not, pressures to invest inhigh technology curative services which carry little benefit to health statuswill dominate and investment in effective disease prevention and healthpromotion will be eroded.

36. Accordingly, the Public Health and Disease Prevention subcomponent isthe centerpiece of the Health Services and Management Project. It wouldprovide for a generation of new information and policies, and for theimplementation of specific, cost-effective measures. The information and

- 50 - AM I

policies would guide the overall health sector reforms and enable the goal ofclosing the gap to be kept constantly at the forefront of national and localdebates about health and health services. The specific measures that would beimplemented would demonstrate the relationship, in a Hungarian context,between modifiable risk factors and disease, and would help to dispel theprevailing mood of pessimism about health promotion and disease prevention.

37. Beginning to close the gap in health status between Hungary andWestern Europe also depends on policies and actions unconnected to the healthsector. It is important, therefore, that the public health policy makingcapacity developed under the Public Health and Disease Prevention subcomponentaddress multi-sectoral issues.

38. The National Public Health Center (NPHC), as a new organization, isnot yet optimally organized to meet the challenges of reducing mortality fromchronic and environmental diseases. The seven institutes that were joined inthe formation of the NPHC are still operating as seven separate organizations.Over the next several years, major reorganization of the NPHC is desirable.However, it is not possible to predict the exact nature and timing of thisreorganization. The Project would, therefore, strengthen the NPHC in waysthat allow the gap in health status between Hungary and Western Europe to beaddressed effectively and that would still allow for more fundamentalreorganization in the future.

39. Program Description. Specifically, the program would establish a newPublic Health Program Unit (PHPU) and a project development budget in theOffice of the GKO.

40. The PHPU would be staffed as follows:

* a Director (with public health and managerial experience);* a Project Manager;* two epidemiologists;* two health policy specialists;* an information specialist;* a communication specialist;* two data analysts;* two research assistants; and* five secretaries.

41. The total staff complement (17) would be built up over the firstthree years. A number of the individuals specified would not be readilyavailable in Hungary, especially the epidemiologists, health policyspecialists, and data analysts. Therefore, young graduates would be recruitedfrom suitable backgrounds and sent abroad for MSc level training beforereturning to take up posts in the PHPU. The epidemiologists may be medicalgraduates, the health policy specialists may be economics graduates, and thedata analysts may be mathematics graduates.

- 51 - AEX 1

42. Some of the staff listed may hold joint appointment between the PHPUand other posts. In particular, joint appointments with the new School ofPublic Health and School of Health Services Management may be attractive.This would assist recruitment and retention of staff. It would also providethe PHPU with a supply of postgraduate students to conduct applied researchand analysis. It would provide the School of Public Health and School ofHealth Services Management with access to teaching material on the latestpolicy and information concerning public health and management in Hungary.

43. Just as the Public Health and Disease Prevention subcomponent is thecenterpiece of the Health Services and Management Project, so the PHPU is thecenterpiece of the Public Health and Disease Prevention subcomponent. Througha Close the Gap Program (CGP), the unit would have a major catalytic effect onthe next generation of innovative public health policies, programs andprojects.

44. The PHPU would grow over time to occupy a central position in publichealth and would advise the authorities at the highest level. This role wouldtake three or four years to develop. In the meantime, the PHPU would have theimportant task of managing the Public Health and Disease Preventionsubcomponent of the Health Services artd Management Project and of running theCGP.

45. Six major functions of the PHPU are described in turn below:

(a) Project management. Overall project management is the responsibilityof the PMU in the MOW. A subsidiary project management capacitywould be developed for the Public Health and Disease Preventionsubcomponent which would have its own project manager andsecretariat. A technical assistance package has been designated toassist the PHPU and this project manager.

(b) Close the Gap Program (CGP). US$2 million per year (in currentprices) would be made available to fund innovative research andimplementation aimed at closing the gap in health status. A total ofUS$14 million (base cost) would be disbursed over the lifetime of theProject for this purpose.

To implement the CGP, it would be necessary to develop administrativeprocedures, peer review and other measures necessary to allocatefinancial resources in a competitive manner that would maximize theimpact on closing the gap in health status. It is essential thatthese procedures be as open and competitive as possible, and thatthey be administered in an efficient and sound manner.

(c) Information. The PHPU would establish a monthly public healthnewsletter to be widely distributed among relevant professionals.This would not be a simple listing of reported disease, but wouldcontain analysis and articles of immediate interest. It would also

- 52 - ANN 1I

contain regular progress reports concerning closing the gap inhealth. Information for this newsletter would be supplied not onlyby the public health service, but also by other agencies - forexample, the NSO.

(d) Policy Development. Despite Hungary's poor health status, there areno well-coordinated national policies on matters such as heartdisease, stroke, preventable cancers, injuries, smoking or alcohol.In the newly reorganized public health service, responsibility forsuch matters is divided and the CNO lacks the staff and analyticcapacity to generate a policy agenda. The PHPU would, therefore,increasingly take on the role of supporting policy formulation andadvising the CMO on public health policy.

The PHPU would be assisted in this task by other parts of the publichealth service, and by other agencies, such as the NSO. The policyformulation role of the PHPU would be greatly assisted andstrengthened by the strategic use of the CGP. Funding decisionswould be influenced by policy agendas on which the PHPU is workingand the results of applied research and program evaluation supportEDby the CGP would feed into the policy work of the PHPU.

(e) Advising the CMO. The CNO presides over a large public healthservice with wide ranging responsibilities for health. The CMO'sability to influence and lead is, however, restricted by the lack ofstaff and analytical capacity reporting directly to him. The PHPUwould, therefore, support and advise the CMO in his many functionsand responsibilities. By strengthening the CMO's role in this way,the Project would deliberately avoid investment in one of theexisting institutions within the public health service and therebyencourage, or at least not discourage, needed reforms.

(f) Interactions with the Schools. The new Schools of Public Health andof Health Services Management would be established in parallel withthe establishment of the PHPU. The potential for productiveinteraction between the PHPU and the schools would be substantial.This interaction would be stimulated by joint appointments whichwould be considered as the PHPU and the schools are being staffed.

46. The global work program for the PHPU would be guided by aninternational steering committee called the Closing the Gap Committee (CGC),which would be directly responsible for funding decisions taken under the CGP.The CGC would comprise six Hungarian members and four foreign senior publichealth specialists from four different countries. The Hungarian members wouldbe able to contribute a multi-sectoral perspective on health policy prioritiesin Hungary and the foreign members would be able to enhance the discussionwith an international perspective. The Hungarian members would be appointedby the CMO with agreement of the Minister of Welfare, the Cabinet Committee onHuman Resources and the World Bank. The four foreign members would be

- 53 - NNEX 1

proposed by the consultants undertaking the technical assistance package andagreed on by the Minister of Welfare, the Cabinet Committee on Human Resourcesand the World Bank. Arrangements would be made for twice-yearly meetings ofthe CGC, with 2 days in committee and 3 days of site visiting at each meeting.Discretion to make minor awards could be granted to the PHPU by the CGC aftera year of operation.

47. The terms of reference of the CGC would be to:

* provide guidance to the CMO and the PHPU on measures to close the gapin health status between Hungary and Western Europe;

* monitor and make public statements about the progress towards closingthe gap in health status;

* be responsible for the allocation of funds available to the CGP tohigh priority activities in the field of public health interventionand research;

* undertake other activity, as it may decide, to improve public healthin agreement with the CO.

48. The Project would refurbish and equip offices needed to house the newunit within the Office of the CMO. The Project would also provide fortraining, equipment and technical assistance, as indicated below.

49. Phasing during Project Pregaration and Imglementation

92 93 94 95 96 97 98 991. Public Health Program Unit

plan xrecruit xopen unit x x

2. Close the Gap Program

establish fund xfund projects x x x x x x xevaluate x x x x x x

3. Close the Gap Committee

select membership x xmeeting twice per year x x x x x x x

-54 -ANNEX }

50. IMplementation Arrangements. The CMO, as the head of the NPHC, wouldbe the person directly responsible for all the activities in thissubcomponent. Day-to-day responsibility for the work of the PHPU would restwith the Director of the PHPU.

51. The following tasks would need to be completed as soon as possible:

(a) define, in detail, the structure, staffing and terms of reference ofthe PHPU;

(b) identify the space which the PHPU would occupy to start the processof arranging for its refurbishment;

(c) identify, in detail, the equipment specifications for the PHPU andstart the process of procurement;

(d) appoint the Director of the PHPU, the Project Manager (who would headthe subsidiary PMU), and support staff;

(e) define, in detail, the terms of reference and the scientific andadministrative procedures for the CGP; and

(f) appoint the members of the CGC and prepare for its first meeting -preferably in late 1992, but mid-1993 at the latest.

52. To support this preparatory activity, and to support theimplementation of the entire Public Health and Disease Preventionsubcomponent, a substantial technical assistance package would be developed.This technical assistance would provide support for all the preparatory taskslisted above and for the ongoing work of the PHPU and the CGP. It would alsoprovide support for the other subcomponents of the Public Health and DiseasePrevention subcomponent.

Chronic Disease Primary Prevention

53. Specific Background. The main determinants of the poor lifeexpectancy at middle-age in Hungary are cardiovascular disease and cancer.The standardized death rates up to age 65 are nearly twice the Europeanaverage for coronary heart disease and nearly 50 percent higher forcerebrovascular disease. Death rates for lung cancer, breast cancer,cardiovascular, and cerebrovascular causes are all high relative to comparablecountries, and also are increasing. In twenty years since 1969 the deathrates for lung cancer have increased by 87 percent for males and 66 percentfor females. For colon cancer similar figures are 116 percent and 87 percentrespectively, and for breast cancer the increase is 66 percent among women.Each year, for men, there are 5,000 lung cancer deaths, 2,000 deaths fromcolorectal cancer, and 900 deaths from cancers of the oral cavity. Amongfemales, there are 2,000 breast cancer deaths, 2,000 colorectal cancer deaths,1,400 lung cancer deaths and 600 cervical cancer deaths.

- 55 - ANNEX

54. The main causes of the high and increasing cardiovascular diseaserates are likely to be diet, smoking, physical inactivity, the personal andfamily consequences of economic hardship, and inadequate medical care forhypertension. While economic hardship and its consequences may have to awaitother developments for improvement, progress is possible and urgent in otherareas. The Hungarian diet derives 40-43 percent of its energy from fat, islow in fresh fruit and vegetables, is low in complex carbohydrates and is highin salt. Obesity is highly prevalent, smoking rates are high, and levels ofphysical activity are low. The dietary and smoking habits of the Hungarianpeople are entirely commensurate with high mortality patterns. The intake ofanimal fat is high and of fiber low, while the prevalence of cigarette smokingis among the highest in Europe. The average consumption of cigarettes among15-84 year olds is 3,154 per annum yielding an average tar consumption of58.8 g. Apparently 50 percent of teachers and doctors smoke cigarettes, whichis a figure close to the national average for adults.

55. The consequence of increasing mortality from heart disease and cancercan be seen in the unenviable record of decreasing life expectancy in the lastforty years. In 1949, 40-year-old men were expected to live until age 71.7,vhereas in 1990, 40-year-old men were expected to live only to age 68.8.Increase in ischemic heart disease can explain about 80 percent of thisincrease in total mortality in males. In recent years, unfavorable social andeconomic circumstances have hampered political action to affect national-levelnutrition and smoking behavior. Because changes in smoking, serum cholesterollevel, blood pressure and physical activity are the major known requirementsfor the prevention of cardiovascular diseases, action in these areas is anurgent priority in the effort to reduce the gap in health between Hungary andWestern Europe.

56. Program DescriDtion. This subcomponent would support the creation ofa demonstration program in one district in the country to develop a Hungarianmodel for disease prevention and risk factor reduction. This CommunityDemonstration Nodel would provide evidence of the feasibility andeffectiveness of community-based prevention approaches to cardiovasculardisease. The main requirement to start a community-based program is to learnmethods by which health behavior and risk factors can be changed in theHungarian context and to develop national expertise in this field. Theintervention methods shown to be feasible and effective in the demonstrationarea would then be used in other Hungarian communities with implications fornational policy development in cardiovascular and other non-communicabledisease prevention.

57. The demonstration model would be conducted in a well-definedgeographical region of Hungary comprised of 20,000-60,000 residents. Theregion should include at least one town of 10,000-30,000 inhabitants, and anassociated rural area containing a similar number of people.. The interventionmodels would be built on those used in such places as North Karelia (Finland)and Stanford (USA). The program would allow an opportunity to design,implement, and evaluate intervention methods appropriate to the currentHungarian situation. This would serve as a demonstration of the potential to

- 56 - ANNEX 1

reduce chronic disease risk factors in the population. In addition, anational anti-smoking campaign would be developed using both printed andelectronic media.

58. The demonstration community would be selected by the NIHP prior toissuing a request for proposals from universities to contract and carry outthe intervention. The entire project would be overseen by a steeringcommittee to be appointed by the spring of 1993. The steering committee wouldinclude (at a minimum) the Project Director, the Scientific Director of theNIHP, a representative of the COP of the NPHC, and two members of theintervention community.

59. Much of the outcome evaluation would be done by the survey teamconducting the Hun-HANES (see Health Surveys program), but additionalevaluation of the process would be built into the contract for theintervention. The Hun-HANES survey team would begin its national survey by anintense sampling of the intervention district (about 1,500 people). It wouldthen return for a repeat survey at the mid-point and again at the completionof the Project. A similar area not receiving the intervention would serve asa control community, and comparisons would also be possible with the countryas a whole, since the Hun-HANES survey would be conducted during this sametime period as the demonstration trial.

60. In addition to the demonstration model, there is also an urgent needto develop a nationwide strategy for health, including the establishment ofpolicies on nutrition and tobacco control. Based on the experiences fromother countries like the US and Finland, the expertise developed in communityprograms can make a major contribution to formulation of national policies.The high prevalence of cigarette smoking demands a public health response atthe national level as soon as possible. The current anti-smoking program ofthe NIHP would be substantially intensified through technical assistance andwith an investment in print and electronic media development to make theHungarian public aware of the hazards of tobacco. The campaign would be basedon public information and would also target physicians and teachers forsmoking cessation. Approaches that have been developed and tested in thecommunity demonstration area would be disseminated, especially through theHealthy Cities network of the European Regional Office for WHO.

61. Phasing during Project PreRaration and Implementation. Planning ofthe demonstration model would be in the first nine months of 1993. This wouldbe done by the NIHP under the leadership of a program Director. Baselinemeasures of health status and risk factors would be made between September1993 and January 1994 (see Health Surveys program). The communityintervention, conducted by a Hungarian university under contract with theNIHP, would begin in January 1994. The anti-smoking activities would beplanned in the first six months of 1993, and developed and disseminatedthereafter.

- 57 -AE 1

92 93 94 95 96 97 98 99

1. Demonstration proj.planning xxxxbase.surv. xxxxconduct iXICK)t xXX XXXXevaluate xx xxxxxx

2. Anti-smoking programplanning xxxdevelop materials xxxxxx xxx xxxconduct campaigns xxxx xxxxx xxx

62. Inglemen&at on rrangent. The National Institute of HealthPromotion would be the responsible agency to carry out all the activities inthis program.

Secondary Prevention of Cancer

63. Saecific Background. Secondary prevention by means of screening isof great importance in preventing unnecessary morbidity and mortality. Sincemuch chronic disease already exists (and some may be unavoidable), secondaryprevention remains an important element of health care. The opportunity foran increasing role of secondary disease prevention is particularly opportunebecause of proposed concomitant reforms in family medicine.

64. Although cancer registration has been obligatory since 1952,reporting levels have been low in most counties and national data on diseaseincidence has not been used effectively. The current method uses a form thatis completed by the physician who diagnoses a cancer, but innovations inregulations are needed to facilitate identification of cases from hospitalcomputer records and for the clerical addition of further information ontothese records. The existing quality of national data does not provide thecomprehensive picture of geographic variation needed to plan, monitor andevaluate primary and secondary prevention programs.

65. Cervical cancer screening is currently available and thought to reacharound 50 percent of the eligible population (20-65 year old females) everythree years. The worsening of PAP smear coverage is, however, thought to beresponsible for the observed increase in cervical cancer death rates andreduction in the proportion of early stage diagnosis in recent years. In1991, the number of smears decreased by 20 percent.

66. Nammography for breast cancer mortality reduction through earlydiagnosis has been well accepted in most western countries but is not readilyavailable to the general public in Hungary. The success of any mammographic

- 58 - ANNEX 1

service depends crucially on adequate and complete call and recall, and on theaccuracy and reliability of ancillary diagnostic services, both radiologicaland pathological. This is lacking in Hungary.

67. The efficacy of screening for colorectal cancer is not asdemonstrable, but limited evidence suggests that fecal occult blood testingand endoscopy may reduce mortality. In 1981-83, only 27,000 out of a possible74,000 samples were collected for analysis. A prospective study of efficacy,in which doubts about lead time and length biases can be allayed, is thereforeclearly indicated before a major national program is launched.

68. During the past, much hypertension screening took place in thepulmonary clinics of the public health system. Although this led to thefrequent diagnosis of hypertension, clinical follow-up was weak and, in manycases, non-existent. The high incidence and poor clinical management ofstrokes and other morbidity related to hypertension is evidence of the failureof this model of preventive and clinical intervention. Today, primary caredoctors have not yet assumed full responsibility for hypertension screeningand control making this a high priority for continuing education in thefuture.

69. Program Description. This subcomponent would ensure thatcomprehensive local data on cancer are available in formulating policy and inplanning to prevent and treat cancer related diseases and promote good health.It would assist in design and implementation of screening programs of proveneffectiveness for secondary prevention. It would also facilitate the use ofcase-control and other epidemiological studies to identify or highlight keylocal risk factors. Strategies would be developed that emphasize concretesecondary prevention to enable cost effective savings on advanced medical careand facilitate cultural acceptance of needed public health policies.

70. An improved cancer registration system would be developed, tested,and implemented nationwide using linkages between hospitals, the cancerregistry, and vital records including deaths. A new system of records forcancer registration needs to be linked in the near future to the medicalrecords that would be used by hospitals to claim performance-basedreimbursements from the Health Insurance Fund. This would ensure morecomplete data gathering than has been possible in the past. The cancerregistry would use social insurance numbers or future health care ID numbersfor personal identification purposes. Activities would include publication ofregistry findings and careful attention to data quality to insure accurateassessment of cancer incidence and cancer treatment services.

71. The program would attempt to increase significantly Pap smearcoverage through a call-recall system that would be developed by the cytologylaboratory system in cooperation with family doctors. The proposed program

- 59- A 1

would increase the extent and amount of appropriate Pap smear coverage to1.7 million cervical cytologies per year with a reliable call and recallsystem in medical practices by 1997. It would require data coordination amongthe 72 cytology laboratories in the counties and the provision of equipmentand training for general practitioners. Women ages 18-64 would be invited tohave Pap smears done by their primary care doctor (or gynecologist if that iswhere the previous smear was done). The registry would be maintained andoperated by the cytology laboratories, and supervised by the NationalInstitute of Oncology (NIO). Studies to assess screening efficacy (such assmall case-control studies) would then be conducted. The training of generalpractitioners in the technique of performing a Pap smear would be one of theimmediate goals of the training program implemented through the primary carereform.

72. The introduction of routine mammography in a single county would beused to examine the feasibility of this method of secondary prevention. Thetrial program, established during the first year of the Project, would beevaluated during the second year. Three additional screening mammographycenters would be established and evaluated if the first unit proves to besuccessful. The performance of all four units would be evaluated bycase-control studies. The women eligible for the service would be aged 50 andolder.

73. The subcomponent would initiate a research program for colorectalcancer screening which would investigate the efficacy of the followingscreening modalities: fecal occult blood tests (FOBT) and endoscopicexaminations. A single FOBT screening program would be developed andimplemented in a selected county. Pilot studies in three additionaldemonstration centers would subsequently provide information on acceptabilityand test sensitivity. Follow-up would include a four-year evaluation ofcolorectal cancer screening, including an endoscopic examination component.

- 60 - ANNEX 1

74. Phasing for groject Prgearation and Imglementation

92 93 94 95 96 97 98 99

1. Pap smears planning xxxcall system xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxcytology training xxxaxxxxxxxxxevaluation xxx xxx xxx

2. Mammographyplanning xxxxxxxfirst unit xxxxxxxxxxxxxxxxxxxxxxxxxxxxevaluation xxxxxnext three units xxxxxxxxxxxxxxxevaluation xxxxx

3. FOBT planning xxximplement screening xxxxxxxxxxxxxxxxxxxxxxxxxxxxxevaluation xx xxxxx

4. Cancer registrydevelopment xxxxxxxxtesting xxxxximplementation xxxxxxxxxxxxxxxxxxxxxxevaluation xxx xxx xxx

75. Imniementation Arrangements. The National Institute of Oncologywould be the responsible agency for all oncological activities in thisProgram. The program would be implemented through: (a) training and equipmentpurchases to improve information processing for cancer registration;(b) training primary care doctors in Pap smear techniques and hypertensionmanagement; (c) training and equipment to develop and evaluate demonstrationprojects of mammography; (d) training and equipment to develop and evaluatedemonstration projects of FOBT; and (e) training to develop and evaluatedemonstration projects of hypertension detection and control.

School Health

76. Sgecific Background. Much of the difference in levels of morbidityand life expectancy between Hungary und Western Europe can be traced tounhealthy behaviors and lifestyles, many of which start in childhood. Inparticular, there are high levels of smoking among children and young adults,and obesity, hypertension, and unplanned pregnancies are common. Theseproblems are made worse by ignorance of the relationship of lifestyles tohealth, and by pessimism about the possibility of affecting changes inunhealthy behaviors. There is currently a need for a system to develop andevaluate school h3alth education curricula, to support the Health PromotingSchools Project (HPSP), to improve school health services, and to establish asystem of regular surveillance of health risk behaviors in school children.

- 61 - AN 1

77. Program Activities. This subcomponent aims to strengthenschool-based health promotion interventions. It would develop and evaluatehealth promotion activities in schools. In particular, the focus would be onimproving dietary habits, preventing the onset of smoking, increasing physicalactivity, avoiding substance abuse, and preventing sexually transmitteddiseases. These would be accomplished by a combination of health educationand creating a healthier school environment, with initiatives on improving theschool lunch program and preventing injuries.

78. The program would improve school-based preventive health servicesthrough training of teachers, health visitors and primary care doctors workingin schools. Training would be for the purpose of improving their skills inhealth education. The current school health care manual would be revised forschool physicians and health visitors to support the aims of the program.These activities would be conducted in collaboration with the NationalInstitute of Pediatrics. Special emphasis would be placed on identifying andtraining one teacher in each school who would act as the coordinator of healtheducation activities. The program would conduct a controlled educationaltrial. Ten schools would receive a structured health education curriculum,and ten would serve as controls, receiving only the usual (minimal) healtheducation. Five of the schools (or more) would be in the CommunityDemonstration Model region and five would be in Budapest. Control schoolswould be matched on community characteristics.

79. The program would develop and evaluate health education curricula ingrades five through eight. The program would be started in the 5th grade infall 1993. This would allow a half-year planning period and time to developthe 5th grade curriculum. In each year, the curriculum for the nextconsecutive grade would be developed. Based on the experiences in the programschools, the curriculum would be revised and disseminated to other schools inthe country. The experiences of other successful school programs (especiallythe positive results in smoking prevention from resistance and skill trainingprograms tested in the 1980's) would be used in the curriculum development insmoking, alcohol abuse and drug use prevention. Similarly, the experiencesfrom nutrition education programs in other countries would be used in thedevelopment of the program. The nutritional program would aim to achievebalanced diets and reduced intake of saturated and total fats.

80. All the students in the 5th through the 8th grades in both the tenintervention schools and in the ten control schools would complete a self-administered questionnaire. The questionnaire would include questions onhealth related behavior, attitudes, beliefs regarding health, norms andskills. Saliva samples would be collected for cotinine measurement on a sub-sample of children to validate smoking prevalence rates. Students would besurveyed annually in grades five through eight. The program would alsoinclude surveys of the teachers' and parents' attitudes and behaviors. Inaddition to this outcome evaluation, process evaluation of all plannedactivities would be done. A twenty-four hour dietary diary would be collectedon the children to obtain basic information on eating habits. The nutritionalcontent of the school lunch would be calculated and, based on the results,needed changes would be introduced, accompanied by training of the schoolcafeteria personnel.

- 62 - ANNE_ 1

81. The program would also support and expand the Health PromotingSchools Project (HPSP), developed by WHO/EC, currently established in tenHungarian primary schools. The program would also create a research anddevelopment program under the control of the Steering Group for the HPSP tosupport innovative school health promotion activities. Awards would be small(maximum US$1,000), and provided on a competitive basis with 20 awards peryear.

82. Finally, the program would develop a national health behavior survey,in collaboration with the National Institute of Pediatrics, to provideinformation for more effective planning of school-based public healthinterventions. A nationaliy representative sample of students from 5th to 8thgrade would be conducted in the first and last year of the school program.This would allow for analysis of differences, if any, between trends inchanges in knowledge, attitudes, and practices among students in the programschools and broader trends nationwide.

83. An annual school health conference would be held, beginning in 1993,which all school health education coordinators and program staff would attend.

84. Phasing during Project Preparation and ImDlementation

Year 93 94 95 96 97 98 99Grade 5 6 7 8Project Preparation xAppointment of cooperationGroup xAppointment ofProject Leader xComplete written plan xCurriculum development5th grade x6th grade x7th grade x8th grade x

Conduct the program5th grade x x x x x6th grade x x x x7th grade x x x8th grade x x

Surveys (program) x x x x x xNational School HealthBehavior survey x x xTeacher trainingcurriculum xCurriculum for visitorsand doctors xTraining and CoursesFor teachers, doctors, visitorshealth education (1 week) x x x x x x

- 63 - ANNEX I

85. Prolect PreDaration and Implementation Arrangements. The programwould be located in the National Institute for Health Promotion, and wouldhave a full-time Director, twe program staff and a secretary. Part-timeassistance from a media specialist, an economist, and other inputs would beprovided on a consulting basis.

Hungarian Health and Nutrition Examination Survey

86. SRecific Background. Although it is well known that the health ofthe Hungarian population is among the worst in Europe and has declined overthe past two-and-a-half decades or so, little is known about the distributionof risk factors in the general population and among the specific high-riskgroups, such as the poorly educated, and people living in small villages.

87. Traditionally, mortality data are voluminous, mostly reliable andfairly accurate. Morbidity data, especially on non-communicable chronicdiseases, are practically non-existent. In fact, nothing is known on thefrequency and distribution of the most common impairments and disabilities.Detailed data on risk factors such as smoking, poor diet, excessive alcoholintake, high blood pressure and physical inactivity are also poorlydocumented. Previous surveys of risk factors are of limited value due toweakness in design, sampling and quality control.

88. There is an urgent need for a high quality health and nutritionsurvey to provide information on the frequency and distribution of selectedchronic diseases, impairments, disabilities and risk factors. Such a surveywould need to measure social factors related to health and knowledge,attitudes and behaviors that affect health. It would need to be designed toprovide the data necessary for policy makers to formulate public healthpolicies and to plan intervention programs.

89. In 1992 the NSO would conduct a Health Interview Survey (HIS) ofapproximately 17,000 households. A sampling frame has been developed andcontract interviewers identified. After a pilot survey, the HIS would beconducted in the last quarter of 1992. A HIS is, however, of limited valuebecause the data obtained is based exclusively on replies to an interview. Itis not capable of providing information on the frequency and distribution ofpathophysiological indices, much less on hidden morbidity. A HealthExamination and Nutrition Survey (HANES) is much more detailed, being designedto supply data on pathophysiological indices, risk factors, somenon-communicable diseases and most common impairments and disabilities.Together, the HANES and HIS would provide reliable and fairly accurateinformation on the health of the population.

90. Broad Goals. The major goal of the examination survey is to providedetailed and current information on a national level on the frequency anddistribution of selected chronic diseases, health risk factors. In addition,data would be gathered on the most common impairments/disabilities andrelevant knowledge, attitudes, and behaviors among the general population andmaybe among specific subgroups at high risk.

-64 - ANNEX 1

91. Obiectives

(a) To provide general population-based information in the Hungariancontext on the link between the major causes of preventable death anddisability. Among others, these causes are coronary heart diseaseand stroke. Some of the diseases of the musculoskeletal system, likerheumatoid arthritis and the dental condition of the population wouldalso be examined. The frequency of selected risk factors, such assmoking, poor diet, high blood pressure, physical inactivity andexcessive alcohol consumption would be examined.l/

(b) To provide this information for specific high risk groups, including:

i) people with low educational attainment; andii) persons living in villages with less than 10,000 population.

(c) To develop the capacity to conduct such surveys, including technicalexpertise and equipment, that could be used subsequently to supportongoing risk factor surveillance and to support the design, conduct,and evaluation of community-based intervention programs.

92. Program Description. This subcomponent would conduct a nationalhealth examination survey using careful methods of sample selection andmeasurement. This survey would be conducted using mobile fieldexamination/interview teams and standard methods for population sampling. Thesurvey would be compatible with the Health Interview Survey, and would beconverted into an ongoing surveillance system for chronic disease riskfactors. The detailed interview would include demographic, socioeconomic,dietary, and health-related questions. The examination component wouldconsist of medical and dental examinations, physiological measurements, andlaboratory tests administered by highly trained medical personnel in mobileexamination centers.

93. The Project would undertake a Hungarian National Health and NutritionExamination Survey (Hun-HANES). An examination and interview of approximately12,000 to 15,000 Hungarians would be conducted so that findings on the healthstatus and risk factor prevalence could be generalized to the entire Hungarianpopulation. The data would be used to estimate the prevalence of majordiseases, nutritional disorders, and potential risk factors. The data wouldalso form the basis for national standards for such measurements as height,weight, and blood pressure. Data would be used in epidemiological and healthsciences research to direct and design health programs and services. Samplingwould allow for rural-urban comparisons of all parameters. The survey would

v/ infomation obtained tbrough the survey would provide decision makers with a more accurate baseline ofinfomation for evaluating the effeotiveness of health promotion and disease prevention activities.

- 65 - A_ I

be conducted by three mobile examination teams over a period of 2.5 years.The initial survey activity would track about 1,500 people in thedemonstration region (see chronic disease primary prevention program), whichwould be revisited after the intervention period for evaluation purposes.After the 2.5 year survey, one of the three teams would continue to collectmore limited data in an ongoing surveillance mode. Every effort would be madeto construct the survey, at least in part, on the sample of the HIS survey soas to improve efficiency and comparability.

94. Several additional activities would be timely and desirable inrespect to improving information on health status by:

(a) strengthening the Department of Population and Health Statistics atthe NSO by the provision of equipment and training;

(b) establishing close links between that Department and the new publichealth service so the needs of the public health service for analysisand evaluation are met without duplication of effort;

95. OutRut Indicators

- Heart disease- Asthma, chronic bronchitis, emphysema- Kidney disease and some other urologic disorders- Osteoporosis- Arthritis, and some other diseases of the musculoskeletal system-

Infectious disease- Dental caries and periodontal disease- Allergies- Some minor psychiatric disorders- Hearing loss- Certain nutritional conditions- Obesity

96. Phasing During Proiect PreRaration and Imlementation

92 93 94 95 96 97 98 99Hun-HANESplanning xxxxxdata collectioncommunity int. xxxx xxxxmain survey xxxxxxxxxxxxxsurveillance xxxxxxxxxx

analysis xx xxxxxxxxxx

97. Project Preparation and Implementation Arranjements. The NSO inclose cooperation and communication with CMO and NPHC would be responsible forcarrying out the Hun-HANES. It would be done in close collaboration with theNational Institute of Food Hygiene and Nutrition (NIFHN) and with the NIHP.

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REPUBLIC 0? MUNMA=

NEALTH SERVICES A1D NANAGEMENT PROJECT

CLOSE THE GAP PROGRAM:

Detailed Program DescriRtion

Background

1. The Close the Gap Program (CGP) will be established under the PublicHealth and Disease Prevention component of the Project. It will be led by aClose the Gap Committee (CGC), which will recommend final awards. The CCCwill be supported by the Public Health Program Unit (PHPU), which will beresponsible to the Chief Medical Officer (CMO). The PHPU will administer theCGP, and will be provided with an adequate infrastructure to implement thistask.

2. The Ministry of Welfare (MOW) has already had limited priorexperience with competitive funding in Medical Universities and NationalInstitutes through the activities of the recently established Medical ResearchCouncil (MRC). The principal lesson learned from the MOW experience is thatthe temptation to distribute research funds equally among institutions must beresisted. This lesson--that not all institutions are able to get an equalshare of limited resources--has been fully taken into account in the design ofthe proposed funding criteria, guidelines and award procedures for the Closethe Gap Program.

Obiective of the CGP

3. The purpose of the CGP is to provide incentives to institutions ofhigher education, primary and secondary schools, hospitals, healthdepartments, communities, and Non-Governmental Organizations (NGOs) to launchnew initiatives in health promotion and disease prevention, improve inter- andcross-institutional collaboration, and integration of teaching and action-oriented intervention programs to begin to close the gap in health statusbetween Hungary and Western Europe.

4. The main objectives to be achieved by the CGP, to be financed by theloan, are:

(a) to stimulate innovative action-oriented and cost effectiveintervention programs in health promotion and disease prevention tocontrol diseases that account for one of the top ten causes of death(e.g. cardiovascular disease, cancer and injuries) or, when and ifthe information becomes available, one of top 5 catses of disability;

- 68 - ANNEX 2

(b) to establish a more substantial and incentive-driven financingmechanism for action-oriented intervention programs and research inpublic health;

(c) to foster high quality action-oriented intervention programs inchronic disease prevention, which could include: (i) longitudinalstudies to demonstrate the relationship between hypertension,obesity, smoking and high cholesterol as related to chronic diseaserisk; (ii) survey research on chronic disease risk factors and onperformance of programs designed to reduce chronic disease riskthrough either primary or secondary prevention efforts; and(iii) evaluation programs designed to reduce tobacco use, improvediet, improve hypertension control, and decrease sedentary life stylein well-defined populations or communities;

(d) to make provision for future public health initiatives which cannotbe anticipated or launched immediately i; order: (i) to reduce thehigh rate of alcoholism, suicide, non-intentional injuries, tobaccoabuse, etc.; and (ii) to encourage coordination and cooperationbetween groups such as health departments, universities, colleges.hospitals, primary and secondary schools, community organizations,NGOs, etc; and

(e) to ultimately overcome the pervasive pessimism with respect toimproving healthy life-styles in Hungary, among the population andmedical profession alike, and create a new confidence that effectiveaction in health promotion and disease prevention could begin closingthe gap in health status between Hungary and Western Europe.

Criteria for Selection of Committee Members

5. The Close the Gap Committee (CGC) will comprise six Hungarian andfour foreign members. They will be nominated by the CMO with the Bank'sagreement, and appointed by the Minister of Welfare. CGC appointments will befor a three year period, with the possibility of renewal. All committeemembers should have recognized international stature in their area ofexpertise. Due consideration should be given to working compatibility amongmembers.

6. Members should represent a mix of health advocacy interests (at leastone with expertise in cardiovascular health, cancer, lifestyle (tobacco,alcohol control, diet) and school health education. Also, members shouldrepresent a mix of disciplines (with professional qualifications in one ormore of the following areas - public health (community medicine),epidemiology, behavioral science, public health training and healtheconomics).

- 69 - ANNEX-2

National Composition

Representing at least four different regions of the countryAt least two with previous grant awarding experienceAt least two with non-medical backgroundAt least one representative from the HOW

International Composition

Representing two or more countriesAt least one with previous grant awarding experienceAt least one with non-medical background

7. The national and international members of the CGC will be selected byMarch 31, 1993. The CCC will hold its first meeting during September 1993, atwhich time the ten members and the CHO will select a Chairperson from amongthe ten members. The Chairperson's term will be for three years. Duringstrategy meetings, the CGC will: (a) decide on the major theme for the year,as well as no more than three sub-themes, (i.e. smoking, or nutrition, orlifestyles); (b) decide on the global amount to be allocated during that year,maximum number of possible awards, and distribution by size of awards; (c)select independent peer reviewers to evaluate and rank proposals according topre-defined criteria; and (d) confirm the timetable for request for proposals,submission deadline, selection deadline, and award of contracts. Uponconfirmation by the Minister of Welfare of CGC's award recommendations, theoffice of the CMO through PHPU, will sign contracts with the winners of thecontest. The contracts will include procedures and regulations concerning theutilization of resources, as determined by the World Bank, and otherconditions set by the CGC.

Number of CGC meetings per year

8. There will be only two CCC meetings per year. The first one will bea strategy meeting where most items listed in paragraph 6 above will need tobe decided. The second CGC meeting will be an evaluation meeting, whererecommendations on awards will be determined, and provided to the Minister ofWelfare for final confirmation of selection.

Periodicity of ProDosals

9. There will be one contest per year only. The timing for invitation,submission and selection deadlines will be established by the CCC with dueconsideration of minimum elapsed time requirements for the various stages ofthe process. It is estimated that, as a minimum, two months should elapsebetween advertisement in professional journals and issuance of theannouncement; three months should elapse between issuance of the announcementand closing date for submission of proposals; three months should elapsebetween closing date for submission of proposals and completion of evaluationprocess; and one month will elapse between selection of winning proposals,

. 70 - ANNEX 2

ratification by the Minister of Welfare, and signature of contracts with thewinners.

Criteria for Selecting ADplicAtions

10. The following selection criteria have been jointly prepared by theHungarian working teams developing the Public Health and Disease Preventioncomponent and with teams of consultants providing technical assistance underthis subcomponent:

(a) Applications can be submitted by groups such as: health departments,colleges and universities, hospitals, primary and secondary schools,community organizations, and NGOs, or jointly by any combination ofthe above.

(b) Applicants will be encouraged, where appropriate, to submitcollaborative proposals: (i) when groups and institutions of thesame region formulate common goals; and (ii) in order to create theconditions for, and to implement target-oriented programs supportedby, additional foreign sources (e.g., TEMPUS).

(c) All proposals should be predominately community based and notindividual clinical proposals. The applications have to consider theimplementation of at least one or more of the following objectives:

(i) generate innovative action-oriented and cost effectiveintervention programs in health promotion and disease prevention tocontrol diseases that account for one of the top ten causes of death(e.g. cardiovascular disease, cancer and injuries) or, when and ifthe information becomes available, one of top 5 causes of disability;

(ii) develop action-oriented intervention programs in public healthto reduce the high rate of alcoholism, suicide, non-intentionalinjuries, tobacco abuse, etc.

(iii) where appropriate, to meet the goal of the proposal, encouragethe regional coordination and cooperation between non-profit groupssuch as universities, colleges, hospitals, health departments,primary and secondary schools, community organizations, and NGOs, inhealth promotion and disease prevention.

11. Proposals which meet the above objectives, within the context of theparticular contest, will include the following information in order toparticipate in the competition: objective, scope, activities, budget, output,timing, evaluation and monitoring criteria.

Financing and Procurement Guidelines

12. Successful proposals will receive financial resources (in convertiblecurrency and forints) for the acquisition of, among others: (a) machines,

- 71 - ANNEX 2

instruments, equipment; (b) furniture, installations, devices; (c) 'goods andrelated services"; (d) consultants and other intellectual services (includinginvitation of guest lecturers); (e) intellectual property; and (f)scholarships, research fellowships, and training.

13. Bank procurement guidelines will apply in the selection andimplementation of winning CGP proposals in the following manner:

(a) Announcements requesting proposals (including TORs and Letters ofInvitation) for each particular CGP contest should at the outsetspecify whether the proposals to be submitted to CGP are to bepredominantly technical assistance/services in content, orpredominantly equipment/goods/facilities in content. Applicants willbe required to include in their proposals, a detailed budget forimplementing the proposal, indicating separately the costs allocatedto technical assistance/services and to goods/facilities net ofoverhead costs.

(b) Program proposals which are predominantly technical assistance/services in content will be awarded under CGP on the basis ofprocedures described in the "Guidelines for the Use of Consultants byWorld Bank Borrowers and by the World Bank as Executing Agency"(August 1981).

(c) Program proposals which are Dredominantl_ ecuiDment/goods/facilitiesin content will be awarded on the basis of procedures described inthe Bank's "Guidelines for Procurement Under IBRD Loans and IDACredits" (May 1992), and Section 1 of Schedule 4 of the LoanAgreement.

14. In order to ensure international competition, there will be a smalladvertisement placed in three internationally well known journals, stating thedate on which the announcement requesting proposals will be issued, as well asthe closing date for submission of applications. The announcement requestingproposals will be made widely available in Hungary, as well as to foreigninstitutions that request it. The announcement will be published andprominently displayed throughout Hungarian universities, hospitals, communityorganizations, and other public places to assure maximum response. Theannouncement will be construed so as to serve both for the purposes of theTerms of Reference and Letter of Invitation mentioned in the ConsultantGuidelines. Accordingly the announcement will be subject to the Bank's priorreview.

15. Proposals which are predominantly technical assistance/services incontent will be financed by direct transfer of resources to the successfulapplicants in accordance with the terms and conditions agreed to in therespective contract. Proposals which are predominantly equipment/goodsfacilities in content will have payments issued to suppliers on areimbursement basis, either through the Special Account, or directly via theBank's standard disbursement procedures, as specified in the purchase order.

- 72 - AMEX 2

Compliance with the Bank's Procurement Guidelines, will be a condition forpost-review approval of such expenditures.

16. Operational expenses arising from the implementation of thesuccessful proposals, should be primarily financed by the applicant's ownresources. Short-term operational expenses critical to the implementation ofdemonstration projects could be financed by the CGP.

17. Applicants who have been notified of an award shcould not undertakeany obligations, sign preliminary contracts or order goods and services inadvance, until they have signed a contract on the approved application withthe PHPU.

Monitoring and Evaluation of the Program

18. PHPU and the Bank will agree on reasonable monitoring criteria toallow for ongoing review and analysis of the CGP. The evaluation of the CGPwill be carried out at the end of the project implementation period, based oncriteria to be agreed upon prior to the award of the first round of contracts.

SAMPLE --Progosed Deadline for SubmpittLng Avlications: September 31

19. Six copies of the applications should be submitted to_________________ of the COP, three in English, and three in Hungarian

(Address: ___).

20. The CGC will inform the applicants by December 15, whether theirapplications had been approved or rejected. The CGC will respond to everyapplicant to: (a) communicate the names and addresses of successfulapplicants, encouraging them to correspond, and (b) return rejectedapplications with a critique that will be designed to be constructive to aidunsuccessful applicants in resubmission for subsequent requests for proposals.

21. Representatives of the groups/institutions, whose applications hadbeen approved, will participate in a seminar in December 1993. During theseminar the World Bank guidelines for procurement of goods and services willbe extensively discussed.

22. Prospective applicants should address their questions to:

Name, address, phone, fax, etc.

-73- ANNEX3

REPUBLIC OF RUMMAY

HEALTH SERVICES AND MANAGEMENT PROJECT

PUBLIC HEALTH AND HEALTH MANAGEMENT TRAINING SUBCOMPONENT

SCHOOL OF PUBLIC HEALTH

A. KEY ISSUES

1. A major reform is currently taking place within the public healthservice in Hungary to strengthen its institutional capacity to meet thedemands placed on it by the poor health of the population.j/ This requiresnew skills in areas such as non-communicable disease epidemiology, policydevelopment and management. Existing training programs are unable to meetthese needs; in fact, a fundamental reorientation is needed in public healthtraining. Poscgraduate training in public health is currently narrowly basedand inadequate to support the challenges of the future. The monopolycurrently held by the postgraduate medical university will be removed andfuture postgraduate training will be developed in the four (currentlyundergraduate) medical universities, consistent with similar reforms in othersegments of higher education.

2. Recommendations for a new system of public health training have beendesigned following detailed examination of five key problem areas:

(a) training content (skills and competencies required);(b) training needs (numbers and grades of staff required by the public

health service);(c) financing;(d) international acceptability; and(e) integration of research and teaching.

Training Content

3. The traditional content of public health training in Hungary isrecognized to be inappropriate for the needs of the new service. Developmentof policies to control non-communicable diseases would require skills inepidemiological methods, biostatistics, health information systems,environmental health, health promotion, medical sociology, anthropology andhealth economics. Supervision of services demands skills in: (a) health careevaluation (to determine whether the services are effective, efficient,equitable and humane); and (b) health service management (to ensure that theybecome and remain effective, efficient, equitable and humane). Advice on

1/ Xealth status of the HNgarian population is among the worst in Europe and has declined in recentyears. See Amex I for a detailed discussion.

- 74 -ANNEX 3

organization of health services would also require skills in health careevaluation. The traditional activities of the service, such as environmentalhealth and communicable disease epidemiology, would require social andpolitical science skills if the detection of problems were to be translatedinto policies that would then to be implemented.

4. Development of appropriate skills, including an understanding of theprocess of local policy development, would require supervised experiencewithin the public health service. However, the trainee also would require asound theoretical base that could be applied to the problems being faced.Consequently, a combination of academic and in-service training would be seenas the optimal solution which is presently not available.

Training Needs

5. Determining the number of public health doctors needed, and their skillmix, is inevitably a somewhat speculative exercise. Attempting to defineexactly the future training needs would be to repeat the earlier mistakes ofcentral planning. Nonetheless, it is necessary to estimate the order ofmagnitude involved to estimate the scale of training resources that would berequired in the future.

6. The first step in assessing training needs is, therefore, art estimationof the number of doctors that would be required to fulfill the new roles ofthe public health service. In the long-term there would inevitably be areduction in the numbers of doctors working in the public health service, ascohorts of non-medically qualified environmental health officers were trainedand recruited, and as bacteriology and other laboratory services moved intohospitals. Primary care would assume responsibility for many other clinicalactivities now undertaken by the public health service.

7. In the foreseeable future, however, the existing over-supply of doctorsmeans that the public health service would almost certainly continue to usedoctors for many tasks that could be done by other graduates. A consequenceof this would be the need to accept that there would be public health doctorswith differing levels of training. Some would require specialist training inall aspects of modern public health but it would neither be appropriate oraffordable to seek to train all staff to this level. While all public healthdoctors would require skills in epidemiology, biostatistics, healthinformation systems, health promotion, and environmental health, a smallernumber of specialists would require more intensive training in those subjectsas well as in health care evaluation, health service management, medicalsociology and health economics. Specialists would provide leadership and ahigh level of expertise; public health doctors with intermediatequalifications would fill posts that do not require the high level of skillsassociated with the full specialist training program.

8. Against a background of experience in Western European countries,examination of the roles identified for the new Hungarian public healthservice suggests that a typical county-level Institute of Public Health (IPH)

- 75 - ANNEX 3

would require no more than five public health doctors who had undergoneadvanced specialist training. In addition, there might be five or six othergraduates in epidemiology, health economics, medical sociology or other socialsciences, and additional staff qualified in health promotion. Additionalmedical support would be provided by public health doctors with intermediatelevel qualifications. Budapest, with a population of 2 million, would requirea larger establishment.

9. Staffing levels of individual municipal-size institutes should reflectthe population that they serve. Those in large cities might have one or twospecialists with additional intermediate-level doctors. Those in towns andvillages would typically be staffed by doctors with intermediate-levelqualifications only, but with support from county institutes. Such aconfiguration implies a total of about 150 specialists and 200 intermediate-level doctors at county and municipal assignments.

10. Up to 50 additional specialists would be required to work in academicdepartments, central government, and national institutes, making a total of200 specialists nationally. Assuming a mean working life of 25 years(allowing for wastage due to premature deaths, temporary or permanentcessation of employment for family or other reasons) and a uniformdistribution of existing staff in different age bands, the annual long-termtraining requirement would be for eight specialists and eight intermediate-level doctors per year. The training requirement for non-medical graduateswould likely be similar.

11. The number of scientific and environmental health staff required couldonly be determined after a review of the tasks undertaken. Experience inwestern countries suggests a possible requirement of about 1,500 environmentalhealth officers nationally. About 60 new environmental health officers wouldbe required each year. The scale of training required for local healthpromotion officers is uncertain, and would have to take into account the needsof local government, i.zdustry, and voluntary organizations as well as thepublic health service.

12. A program to train health service managers has been designed under aseparate subcomponent of the Project and a TEMPUS program. It overlaps withmany areas of public health training. Those responsible for these programshave estimated that there is an annual requirement for 15 new health servicemanagers per year.

13. The purpose of conducting these calculations is not to determine anexact requirement. Rather, it is to determine the order of magnitude. With atotal requirement for medical and non-medical specialists of under 25 peryear, it is difficult to justify the development of specialist academictraining in more than one location. Furthermore, there is a strong case,simply on the basis of economies of scale, in addition to the likelyeducational advantages, of linking training of those working in public healthwith that of health service managers. In contrast, it may be appropriate todecentralize training of environmental health and health promotion officers.

- 76 -

Financing

14. Past experience of insecure funding has engendered concern among thoseinvolved in designing the new public health training program. Traditionally.financial resources intended for public health were diverted to other uses.Consequently those involved in decision making consider it imperative that atraining program should have funding that is guaranteed and cannot betransferred to other uses. In particular, there is concern that funding givenon an open basis to universities might be "hijacked" by clinical departments.

International A¢ceRtability

15. Currently, there are no training programs of an internationallyrecognized standard for public health specialists in Hungary. There is astrong desire to ensure that any new system introduced in the future shouldmeet such standards. The Hungarian government has expressed a desire to jointhe European Community (EC), and is likely to do so by the end of the century.Exchanges between public health doctors in Hungary and the rest of Europe willdepend on compliance with EC regulations for the free movement of physicians.Mutual recognition of qualifications in public health medicine is poorlydeveloped within the EC, with only France, Ireland and the United Kingdomproviding internationally recognized specialist qualifications, although thisis expected to change. The criteria that must be met are set out in a 1975directive on medical training. For a training program to meet these criteriait must consist of theoretical and practical components, be supervised by adesignated body, be located in an approved institution (university or healthauthority), and have a minimum four year duration. A Hungarian program thatwould meet these criteria might have the following composition: one yearsupervised hospital practice; one year at a school of public health; and twoyears in supervised training posts in public health medicine. Although thereare no specific international regulations on the training required bynon-medical graduates working in public health, there is a strong case fororganizing such a corresponding program.

Integration of Research and Teaching

16. Training is only one component of the work for those involved inpostgraduate education. The maintenance of high quality teaching at thislevel is dependent on the continuing involvement of academic staff inresearch. The existing Academy of Science has had guaranteed funding, withthe result that there has been little incentive to develop appropriate andhigh quality research proposals. Staff have been free to pursue their owninterests, regardless of the relevance and value of the work. While somemoney would be required for the basic research infrastructure, there is astrong case for arguing that most research funding should be competitive.

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B. STRATEGIES FOR REFORN

ObjectivogL

17. The objective of the reform would be to create programs for postgraduatetraining in public health (including epidemiology, health economics, healthpolicy, health services, and health promotion) which would build on existinginitiatives at several institutions and which would provide the humanresources and the capacity to conduct research that would allow the gap inhealth status between Hungary and Western Europe to be closed.

Policy Qptions

18. There is general agreement that the new training program should bebroadly based, should combine academic and service components, and should meetinternational standards. The main issues to be resolved concern the structureand location of academic training.

19. Two options have been proposed: (a) developing postgraduate training inexisting institutions (universities); and (b) establishing a new, independentschool of public health. Both options must be considered against therelatively low training requirements identified above.

20. Regarding the first option, existing universities have rell-establishedteams with experience in teaching and research and, in some cases, links withlocal public health institutes. Additional staff would, however, be required.A link with a university would provide a guarantee of quality in terms ofappointments of academic staff and qualifications. Development ofpostgraduate training programs would be consistent with the ex'sting TENPUSprogram. Staff would have access to existing computers and libraries.

21. There are, however, two major disadvantages with this option. First,there would be substantial overcapacity if postgraduate training was to beoffered in all five medical universities. The figures indicated above suggestthat Hungary could only support one training program for medical and socialscience graduates. Second, resources provided by the university could besubject to competing priorities of university rectors. They may be divertedfrom public health to other areas, providing uncertainty about plannedtraining programs.

22. The second option is to create a new School of Public Health which wouldbe financially independent of the universities. This would protect its budgetagainst attempts from other disciplines to corner its resources. Withoutinvolvement of a university, however, there would be no guarantee of qualityof appointments and qualifications, making it difficult to gain internationalrecognition for Hungarian public health training. Also, major capitalinvestment for buildings, computing and communications equipment, and libraryfacilities would be necessary. These fixed costs would be very high in terms

- 78 - ANNEX 3

of the number of students being trained. The last of these would duplicatefacilities already available in the medical universities. New staff wouldhave to be recruited, and it is unlikely that high quality academic staffcould be recruited from within the country without leading to a seriousdepletion of staff in the existing medical universities.

23. The MOW has already initiated major changes in public health trainingwhich currently include the following:

(a) amalgamation of departments of hygiene and social medicine in somemedical universities;

(b) redesigning of the undergraduate curriculum;(c) development of new methods of training, moving away from didactic

teaching; and(d) development of postgraduate training at the present undergraduate

medical universities.

24. The early process of change is being supported by a grant of US$500,000from the EC TEMPUS program. The principal components of the TENPUS programinclude:

(a) visits by Hungarian academics to academic public healthdepartments in Western Europe and exchange of teaching material;

(b) teacher training;(c) infrastructure support (supply of computers, books, teaching

equipment).

25. The TEMPUS program cannot provide all of the resources that will berequired by the proposed reform. The activities to be financed by theproceeds of a World Bank loan would, therefore, be complementary to the TEMPUSprogram.

C. DETAILED PROJECT DESCRIPTION

26. The subcomponent would support seven major program activities:

(a) the establishment of a School of Public Health in cooperation withthe medical universities;

(b) the development of a Masters degree program in public health formedical and non-medical graduates;

(c) the development of two-year supervised placements to achieveaccreditation in public health medicine;

(d) the establishment of a retraining program for doctors in the publichealth service;

(e) the establishment of a Field Epidemiology Training Program (FETP);(f) fellowships to pursue Masters and PhD degrees abroad; and(g) the establishment of nourses for environmental health officers and

health promotion and other specialists in the medical universities.

- 79 - ANNEX 3

Proposed Action Plan

27. The MOW has chosen to create a School of Public Health which combinesthe advantages of both options described earlier. It would ensure financialindependence to provide stability for public health training, and wouldprovide links with universities to ensure standards of quality, and access tofacilities such as large computers and libraries. This is a novel situationfor the Hungarian higher education system but it is one faced in severalwestern countries that have a history of pluralist funding of universities. Asolution adopted elsewhere is to establish an independent school within auniversity. The school would have complete financial autonomy but staffappointments and examinations would be conducted ikccording to universitystandards. Central services, such as libraries a', large computers, would beprovided by the university and the school would cintribute to their cost.Analogous situations are beginning to develop in Hungary with the creation ofintermediate-level institutions such as those used to train social workers.These are under the administrative control of the university but haveearmarked funding.

28. Location. The School of Public Health would be situated in Budapest onthe site of the National Public Health Center. It would be independent butprofessional standards would be accredited by Semmelweis Medical University inBudapest.

29. Management. An independent management board consisting ofrepresentatives of the medical universities, Ministries of Education andWelfare, National Institutes, County Public Health Institutes, and otherrelevant organizations would be established. The board would also include twosenior academics from major schools of public health in other countries.Operational management would be performed by a Director appointed by theManagement Board.

30. Funding. Core funding for the School would come initially from the MOWthrough the National Public Health Center (NPHC). While this approach wouldprevent funds going to other areas of medical training, reliance on a singlesource of funding would lead to long-term vulnerability. The trainingprogram would only be secure as long as the total budget for the NPHC wasadequate. More diverse funding would provide a degree of protection. Thus,in future, funds would also be sought from other bodies with an interest insupporting public health training. Guaranteed funding could also lead tocomplacency, especially since the School would be in a monopoly position. Itis essential to devise a formula that would provide appropriate incentives toprovide high quality training. For these reasons there should be a gradualshift away from reliance on core funding and towards tuition fees provided byvarious public and private bodies and by the students themselves. The exactnature of future developments would depend on other changes in the system forfunding postgraduate medical education. Incentives for high quality teachingmust exist. Initial funding could be zequired to develop a research capacitybut thereafter research funds should be sought in open competition with otherinstitutions.

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31. While most of the funding required for postgraduate education would beused to support institutional developments, it would also be necessary todevelop mechanisms to support those being trained. If high quality publichealth doctors were to be attracted, they would have to receive adequatefinancial remuneration. Adequate funds would have to be made available to paysalaries to trainees that were at least roughly comparable with those receivedby other doctors in training. This could require a supplement to compensatefor loss of out-of-hours payments, as is the case in the United Kingdom andother western countries.

32. Staffing. Staffing would be a major problem in the short-term. Somestaff could wish to transfer from other universities and the NationalInstitutes. They would need to meet university requirements for academicappointments. There would be an urgent need for high quality training ofstaff in public health medicine and in specific disciplines, includingepidemiology, medical statistics, health promotion, environmental health,health services management, health economics, medical sociology andanthropology, and nutrition.

33. A possible list of the staff required, and their skills, is shown below:

Professional Notes forShared Posts

Public health medicine 2 (a)Epidemiology 2 (b)Medical statistics 1 (c)Health promotion 1 (d)Health services management/financing 1 (e)Health economics 1 (f)Medical sociology 1 (g)Nutrition and food hygiene 1 (h)Environmental health 1Occupational medicine 1Radiation hygiene 1

Total individuals 13

Total whole-time equivalents(assuming linked posts split 50:50) 8

Clerical and technical

Administrator 1Secretaries 3Computer officer 1

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Notes for possible shared posts:

(a) one joint appointment with a county Public Health Institute;(b) one with an interest in chronic diseases, one with an interest in

communicable diseases. Research and teaching links with specialistsin the National Public Health Center (NPHC) (or its successorbodies) should be considered;

(c) joint appointment with a medical university;(d) joint appointment with the National Institute for Health Promotion

(part of NPHC);(e) joint appointment with the Social Insurance Administration,

hospital, or School of Health Management;(f) joint appointments with a non-medical university;(g) joint appointments with the National Institute of Nutrition;(h) joint appointments with National Public Health Center.

34. Relationships with Other Organizations. It is recognized that highquality work requires a critical mass that would be difficult to produce withthe structure described. It is most important that staff develop strong linkswith individuals with similar skills in other organizations. This could befacilitated by joint appointments, although the disadvantage of this would bethat the other work could encroach on the work of the School. The director ofthe School would, therefore, need to agree to work programs and timecommitments to ensure that this did not happen.

35. The School would have especially close links with the proposed School ofHealth Services Management. Teaching staff from each school would participatein the work of the other. Certain modules would be taught together. Exactdetails would be determined in due course, but would probably include healthcare evaluation, organizational theory, management, health economics, andmedical sociology. Additional links could be obtained through honoraryappointments of staff of universities, national and county institutes, and theSocial Insurance Administration. In return, these staff would provideoccasional teaching. As with permanent appointments, it is important toensure that honorary appointments meet university standards.

36. Timing. The long-term training program described above cannot bestarted at once. A possible starting date, contingent on the availability ofexternal funds, would be autumn 1994.

Training Programs

37. With the capacity created by the new School of Public Health, and withadditional resources of the NPHC, it is proposed to establish an array oftraining opportunities in which the School would provide the main academiccomponents.

38. The School would offer training leading to a degree equivalent to an MScor MPH. The exact titles of the formal qualification would depend upondevelopments in the reform of the higher education system in Hungary. The

- 82 - ANNEX 3

School would also offer diploma courses run in association with the fourmedical universities. These would normally be taken part-time, and might bespread over a year.

39. All programs at the School would be modular and would be open to medicaland non-medical graduates, Diploma courses would count as credits towardsmasters courses. Subjects taught would include epidemiology (with an emphasison epidemiological methods and chronic diseases), health information systems,communicable disease control, medical biometrics, health care evaluation (togive skills for needs assessment and planning), health economics,environmental health, and health promotion. Some of these subjects would betaught in collaboration with the new School of Health Services Management.

40. Doctors currently working in the public health service who would wish tomove towards specialist accreditation could take the Diploma in Public Health(DPH) to exempt them from part of the accreditation program. Specialistaccreditation would, however, be more usually pursued via higher-leveltraining. This would be of three-years duration and entry would be contingenton having completed at least one year in clinical medicine after basic medicaltraining. One year of specialist training would be spent in a formal academiccourse in a school of public health (in Hungary or abroad), with the remainingtwo years being spent in designated training posts that would be supervised,meet certain requirements with regard to access to libraries and computers,and provide continuing in-service training. A modification of this scheme mayalso be appropriate for non-medical graduates embarking on careers inepidemiology, public health or health policy.

41. Intermediate-level medical staff would require short courses consistinglargely of epidemiology, biostatistics, health information systems,environmental health, health promotion and some health administration.Initial training courses would be of twelve weeks (six modules of two-weekseach) over the course of a year. Completion of the twelve weeks would allowentry into an exam for a DPH.

42. A monopoly in postgraduate public health training should not be accordedto the new School. Several of the medical universities would also begingiving postgraduate training in public health. Although the numbers involvedeffectively preclude offering MPH-equivalent degrees at more than one locationin Hungary, the universities should develop a role in continuing education,offering certain components of the diploma courses, and they should beinvolved, through the management board, and through joint and honoraryappointments, with the training undertaken at the School of Public Health.They might also develop short courses of three to six months leading todiplomas in environmental health and health promotion. The medicaluniversities are undertaking increasingly high quality research, and theywould be suitable locations for research training and for PhD programs.

43. Overseas MSc Training. The most immediate requirement is for training ofacademic staff for the School of Public Health itself. This should take theform of MSc courses outside Hungary in Public Health Medicine and in specific

- 83 - ANNEX

disciplines, including epidemiology, medical statistics, health promotion,health services management, health economics, medical sociology andanthropology, environmental epidemiology, and nutrition. The firstindividuals should commence studies in 1993. It would be impossible to ensurethat those being trained overseas remain in the Hungarian public healthservice; some are likely to emigrate or seek employment elsewhere in thecountry, in either academic or public health posts. Consequently a wastagerate of 50 percent has been assumed.

44. The TEMPUS Program. This program would cover living expenses and travelfor five MSc courses in 1993-4 in the U.K. for staff of the medicaluniversities. Bilaterals could make available some additional funds but thesewould be inadequate to cover the full tuition fees. Consequently the Projectwould include tuition fees for the MSc courses planned under the TEMPUSscheme. In total, the Project would finance 27 complete MSc courses toprovide staff for the School of Public Health and tuition fees only for anadditional five MSc (TEMPUS) courses to further strengthen the capacity of themedical universities. These MSc students would commence as follows: eight in1993, ten in 1994, five each in 1995 and 1996, and four in 1997.

45. Overseas PhD Training. The need to create rapidly a cadre of youngHungarians conducting public health research of international standard,requires that a few promising scholars receive doctoral level researchtraining abroad. The Project would cover the costs of four doctoral students,two starting in 1993 and two in 1994.

46. Overseas Field Epidemiology Training Program (FETPL. In order toprovide exposure to best practice in field epidemiology, three Hungarianswould attend the two-year FETP at overseas training centers. This would havethe added advantage of training a nucleus of staff able to take over and runspecialist training in field epidemiology. One would commence in each of1993, 1994 and 1995.

47. Training of Other Health Care Professionals. Training programs inenvironmental health and health promotion would be established. These shouldbuild on existing expertise. Programs in environmental health might beestablished at the Postgraduate Medical University, the Medical University ofSzeged and the Medical University of Debrecen. Health promotion trainingmight be established at the Postgraduate Medical University and the MedicalUniversity of Pecs.

48. Short Course Training. Existing public health doctors would requireretraining. In line with the long-term training requirements identifiedabove, the retraining needs of intermediate-level and specialist medical stafflevel differ. The approach is to run a modular course, with intermediate-level doctors taking core modules only. Those taking the Diploma in PublicHealth (DPH) would take six modules, and could join the Field EpidemiologyTraining Program. Each module would last two weeks.

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49. Seven suggested modules are listed below (* indicates core modules):

(a) control of communicable disease; *(b) control of non-communicable disease; *(c) promoting better health; *(d) evaluating health service interventions;(e) health priorities and priority-setting;(f) managing health services and health administration; and(g) environmental and occupational health.

* core modules

S0. Public health doctors are older, on average, than other occupationalgroups; 50 percent are over 50 years old. Consequently, as there would likelybe a high rate of retirement in the next few years, it would not beappropriate to offer retraining to everyone. It is suggested that it shouldbe made available at intermediate-level to approximately 60 doctors and, atdiploma level, to 180 doctors. Allowing for class sizes of 20, the corecourse would be run four times per year for three years and the non-corecourse would be run three times per year for three years. The expected mix ofstaff responsible for developing and teaching each module is as follows:

Control of communicable diseasePublic health doctor and epidemiologist

Control of non-communicable diseasePublic health doctor, epidemiologist, andenvironmental health specialist

Promoting better healthHealth promotion expert, andepidemiologist

Evaluating health service interventionsPublic health doctor and social scientist

Health priorities and priority settingPublic health doctor and health economist

Managing health services and health administrationSocial scientist and health servicemanagement expert

Environmental and occupational healthEpidemiologist and social scientist

51. Staff could be drawn from existing Hungarian academic institutions.Development of the modules would be undertaken in a partnership between awestern academic center and the Hungarian teaching staff. An appropriate

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model would be for two Hungarian teaching staff to attend an academic centerin a western country where a similar module is being taught. They would thenadapt the material so that it was relevant to Hungary and then would translateit. The estimated development costs, including travel, tuition fees, livingexpenses, consultancy fees, and teaching material production costs would beUS$20,000 per module. Some of the modules would also be used by the School ofHealth Services Management.

52. Establishment of a Field Egidemiology TrainLng Program (FETP). A FETP,with elements run by CDC, Atlanta, would be established at the NPHC with closelinks to the School of Public Health. The FETP will be within the MPHC, inthe Office of the CHO for the first two years, with affiliation shifting tothe School of Public Health once it is fully established. For its first twoyears a foreign consultant would closely supervise the program. Thisconsultant would be replaced by a Hungarian who had followed an FETP or an MScabroad. Public health doctors seeking specialist expertise in fieldepidemiology would spend six months or a year in the program as part of thelrsupervised training after completion of the MPH.

53. In-Service Training. The second and third years of the public healthaccreditation program would take place in county and national public healthinstitutes. Some posts at the National Public Health Center would providespecialist training in field epidemiology and would be supervised by staffwho, initially, had undergone training on the Field Epidemiology TrainingProgram outside Hungary. A designated individual would be responsible fortraining in a particular post. A national supervisory body would beestablished, consisting of staff from the School of Public Health, the medicaluniversities, and the county and national institutes of public health.Members of this body would inspect in-service training locations annually.Certification of the training in-service location would be conditional onmeeting an adequate standard. This would involve ensuring that certainfacilities were available, such as libraries and computers, and that thecontent of training was appropriate. A mechanism in use in some westerncountries is for the visiting inspection team to interview the trainee andtrainer separately and then to discuss issues raised with them together.

54. The goal of a better trained public health service would be achieved bythe Project through the following: (a) the provision of facilities, books andequipment for the School of Public Health; (b) technical assistance forcurriculum development, the setting of standards, and the establishment ofsupervised placements; (c) development of course modules for retraining ofexisting doctors in the public health service; (d) technical assistance andlong-term consultancy for the establishment of a FETP; (e) direct training oftrainers and leading specialists abroad; and (f) the establishment of coursesfor environmental health officers and others in the medical universities.

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Phasing During Project PrenarAtion and Inlementation

55. The actions described below are listed under separate headings todistinguish those covered by the TEMPUS project and those to be covered by theWorld Bank relating to retraining and long term training.

1992

Project Preparation

Initiate establishment of legal framework. Appointproject steering group comprising a representative ofeach medical university and the public health service.Identify buildings and equipment needs for the School.Agree to management structure of the School with medicaluniversities. Agree to formal link between the Schooland one or more medical universities. Agree on accessto libraries and other relevant facilities. Identifyfirst candidates for training abroad. Identifyfacilities required for training environmental healthand health promotion staff.

TEMPUS

Western/Hungarian joint review of changes inundergraduate public health training withinmedical universities introduced during 1991/92.Provision of communications, teaching equipment,and computers for postgraduate training in medicaluniversities. Provision of books and journals forpostgraduate training in medical universities.Retraining of staff of medical universitiesthrough short courses given in Hungary and abroad.Study tours to UK. Four MSc courses abroad forstudents from medical universities.

1993

Project Implementation

Develop seven modules in specified aspects of publichealth. Complete establishment of legalframework. Commence refurbishment and equippingof School of Public Health. Appoint advisoryboard for School of Public Health. Appointsupervisory board for in-service training.Make initial appointments to School of PublicHealth. Obtain university approval for coursesand examinations. Plan PETP. Three MSc coursescommence abroad. Tuition fees are provided for only

- 87 - _M 3

5 MSc courses abroad (other costs covered by TEMPUS).Two PhD training programs commence abroad.One EIS trainee commences study abroad.

TEMPUSWestern/Hungarian joint review of introduction ofpostgraduate public health training within medicaluniversities introduced during 1991/92. Provisionof communications, teaching equipment, andcomputers for postgraduate training in medicaluniversities. Provision of additional books andjournals for postgraduate training in medicaluniversities. Retraining of staff of medicaluniversities through short courses in Hungary andabroad. Study tours to UK. 5 MSc courses abroadfor students from medical universities.

1994

Project Implementation

Conduct 21 two-week modules.Open the School of Public Health.Commence diploma and MPH courses.Appoint acting director and commence FETP.10 MSc courses abroad.2 PhD training programs commence abroad.2 PhD training programs continue abroad.1 EIS trainee commences study abroad.1 EIS trainee continues study abroad.Commence training in health promotion andenviromental health at medical universities.

TEMPUS

Final review of program.

1995

Project Implementation

Conduct 21 two-week modules5 MSc courses abroad4 PhD training programs continue abroad1 EIS trainee commences study abroad.1 EIS trainee continues study abroad.

- 88 - QENE 3

1996

Project Implementation

21 two-week modules.5 MSc courses abroad.2 PhD training programs continue study abroad.1 EIS trainee continues study abroad.

1997

Project Implementation

4 MSc courses abroad.

Implementation Arrangemts

56. A steering group to establish the School of Public Health would be setup comprising the CMO and a representative of each medical university, andnominated by each rector during the spring of 1993. This would subsequentlyform the nucleus of the advisory board of the school.

57. In addition, a major technical assistance contract would be let tosupport all aspects of the component during the spring of 1993.

- 89 - ANEX 4

UREPEIMC OF HUNGAR

HEALTH SERVICES AND MANAGEMENT PROJECT

SCHOOL O NEhALTH SERVICES NANAGEMENT

A. KEY ISSUES

1. Reducing the gap in health status between Hungary and its neighbors willrequire a coordinated effort across many sectors.1 Action is urgently neededto reduce the prevalence of risk factors, such as inadequate diet, smoking,sedentary lifestyle and lack of social support. The public health subcomponentof the Project is designed to meet this need. In addition, health services areneeded to cope with problems that are not going to be addressed in the short-runby improved promotion of healthy lifestyle, reduction in environmental riskfactors and prevention of diseases.

2. At present, financial resources devoted to the health sector (5.6 percentof GDP) are not used in an effective and efficient manner. There are imbalancesin the distribution of resources and services by type of care (primary care,tertiary care and social services being the major neglected areas) and by region(the smaller and more remote regions being under- serviced). Primary care is inan embryonic stage of development and still poorly integrated into the globalprovision of care; hospital-based services are costly and ineffective intreating many common problems.

3. Instltutional Capacity. The health sector's weak institutional capacityin policy-making, planning, management and evaluation is at the root of manyproblems. Decision-making is, at best, bureaucratic and arbitrary due to thelack of clear policies. As a result, inefficiency is widespread, resources arenot used effectively, and the potential impact of good health care on healthstatus is lost. Current modalities in treatment may even have a negative impacton health due to unnecessary or below-standard interventions, such as prolongedhospitalization, dangerous radiology tests and surgery done with poor aseptictechniques.

4. Lack of managerial skills has become a key issue in the success of proposedreforms for the health sector. The current managing "triumvirate" in hospitals(medical director, nursing director and economic director) have, in most cases,not received adequate training to prepare them for the challenges of the future.New skills are needed in decision-making, planning, communications, negotiations,to name but a few. Hospital directors will have to manage, not simplyadminister, their services.

1/ 3.4th status of th lunsari population is in8 the worst in Europe and has declined in recentyaza. 8ce Annex 1 for a detailed discusson.

- 90 - ANNEX 4

5. Decentralization. Decentralization has modified the respective roles ofthe MOW and of local governments. At each level, policy-making has become acentral task that requires qualified personnel. Decentralization in planning,decision-making and management requires much greater participation by health careproviders. Greater autonomy for hospitals requires greater responsibility andaccountability in setting priorities and objectives, allocating resources andmanaging resources (human, physical and financial). A full-time commitment isnecessary and more sophisticated management skills are needed than were necessaryin the past.2

6. Efficiency. The search for greater efficiency has also triggered a processof rationing of resources. This requires improved productivity, upgrading andredistribution of resources, introduction of systems to monitor delivery ofservices, and improved quality of care. Currently, resource constraints are asmuch due to imbalances as to actual shortages. The number of medical doctors perpopulation is higher than in many OECD countries but the number of nurses islower. The number of hospital beds per 10,000 population is above the OECDaverage but beds are unevenly distributed regionally and many institutions do notprovide acceptable standards of care.

7. Many of the proposed financing reforms in the health sector and socialinsurance system also seek improved efficiency. This will make management morecomplex as reimbursement of health care institutions move to performance-basedsystems. Such reimbursement schemes require greater monitoring of expenditureand more accountability. New computer systems will be implemented, makingpolicy-making and management increasingly dependent on reliable and innovativeuse of information.

8. Training Programs. Although efforts have been made recently to providepracticing managers with new knowledge and train them in new skills, there areno systematic and organized postgraduate training programs in health servicesmanagement.3 There are few teachers trained specifically in healthadministration4 and there is a limited understanding of what would be requiredto initiate such programs in the future. Efforts currently made rely almostexclusively on foreign assistance of a temporary nature and are not well

2 At present, medical directors, although equal to their econciic and nursing counterparts inprinciple, play the leading role as 'primem inter pares." Yet, they devote most of their time toclinical and other professional aectivities, with management remaining a marginal activity.

S/ The nstitute for Postgraduate Studies in Economics, at Budapest University of Economics, offerspart-time short-term courses for heaLth services managers. The Postgraduate Medical University inBudapest also offers limited training in manag8ent to medical doctors and nurses. The EuropeanHealth Management Association, wmder the sponsorship of the EC/PHARE Program, offered a ten-month'Training of Trainers' program in 1991 to potential trainers. Also, an EC/PHARE grant has recentlybean awarded to a consortium of medical universities for short-term training in management inHungary as well as placements in Italy, the Netherlands and Britain.

g/ The Budapest University of Economics teaches basic business management courses and the medicaluniversities teach health related disciplines, but none has experience in teaching health servicesmanagement.

- 91 - ANNEX 4

coordinated. A significant risk is that an uncoordinated introduction ofsubstandard short-term courses could retard the long-term professionalsdevelopment needed to respond adequately to future needs in the health sector.

9. Management Needs. As Hungary engages in the process of decentralizing itshealth services and of rationalizing the use of health care resources, it needsa greater number of professionals qualified in policy-making and in management,with the knowledge, skills and attitudes commensurate with the challenges of theproposed reforms. Such personnel is not currently available and no institutionhas the required capacity to train them.

10. Hospitals of an average size of 500-600 beds will need, at minimum, sixtop-managers (general-director, medical services, nursing, auxiliary services,finance and personnel). Requirements for middle-management personnel would bein the range of 130-150 per institution, calculated conservatively on the basisof 25 medical and other departments/services per average hospital. The totalnumber of personnel in this range requiring upgraded education would be up to20,000 for the hospital sector alone. Other institutions, such as polyclinics,primary care clinics and rehabilitation centers will also require trainedmanagers. In total, a conservative estimate would be upgrading of training needsfor up to 900-1,000 high-level managers and 20,000-25,000 mid-level managers.

B. STRATEGIES FOR REFORM

Objective&

11. The broad goal of creating a School of Health Services Management would beto strengthen the health sector's institutional capacity in policy-making,planning, management and evaluation in support of the effort to close the gap inhealth status between Hungary and Western Europe.

12. The objective of the School would be:

(a) To establish a two-year postgraduate (masters level) program inhealth services management adapted to Hungary's needs, and meetinginternational standards. It would offer a variety of learningexperiences, including academic and professional cour3sa, field workand a supervised residency. This program would be open tocandidates from various disciplinary and professional backgroundsand would be expected to become the entry level qualification forhealth services management positions. Enrollment would initially befifteen students per year, chosen through a selective process; fourgroups of students would have graduated by the end of the Project(one would have completed one year in the program).

(b) To develop a continuing education infrastructure to attend to theneeds of practicing managers. After assessing needs, the Schoolwould develop training sessions on topics regarded as a priority bymanagers and policy-makers. Format would vary according to topic

- 92 - ANNEX 4

and other factors, like managers' capacity to take leave from theirwork in the services. Creation of a continuing education programwould provide health services managers with opportunities forprofessional improvement throughout their careers. Trainingactivities would reach the following target groups: managers ofhealth care institutions (public and private), government agencies,NSIA, representatives of local governments, and other groups activein the implementation of the reforms, such as general practitionerswho would manage their own private practice. These activities wouldbe organized on a regional basis (Debrecen, PScs, Szeged) with thecollaboration of local universities.

(c) To create a research infrastructure (with a view to eventuallyoffering a PhD program) in health services management. In additionto creating a basic physical and material research infrastructure,this subcomponent would focus on bringing up to Internationalstandards, the teaching staff's capacity to design researchprotocols, to write applications for grants, to conduct researchwork in health organizations, and to publish results. Seminarsconducted by well established researchers would be conducted everyyear. Participation in the international research network would bestimulated. Training in research would develop a local capacity toconduct applied research in health services evaluation and analysis.

P01Lie O2tiOns

13. A range of policy options must be addressed in the following areas: (a) thetype of training that should be offered (academic, experiential, undergraduate,postgraduate,); (b) the institution(s) that would be responsible for suchtraining (universities, Ministry of Culture and Education, Ministry of Welfare,others); (c) the activities and target populations (retraining of practicingmanagers and policy-makers, training of future personnel, research,consultation).

14. Training Models. Since there is no tradition of policy-making andmanagement training in the health sector in Hungary, there is a need, indeed anopportunity, to reflect on the type of training most likely to respond to thecountry's future needs. Many alternatives are available: (a) European versusNorth American; and (b) health administration training versus businessadministration training. Focus can be on concepts and theories, or on methodsand techniques. Hungary is in a good position to become a leader in Central andEastern Europe in the training of health services management, because of itsresources and experience in tertiary education, the advanced stage of its healthcare reforms and its extensive network of contacts with foreign institutions.To achieve such a leadership position, it would be necessary to apply quickly theprinciples that have been learned over the past 40 years in other countries and

. 93 - ANNEX

that have become internationally recognized standards.5 Also, as Hungary wishesto integrate into the European Economic Community, it would need to consider theadvantages of harmonizing with European standards.

15. Foreign experience has demonstrated that business oriented managementtraining by itself is not appropriate to the needs of the health sector,particularly in countries where services are principally delivered through thepublic sector. Health care institutions require, for their management, specificknowledge and skills. This justifies managers receiving a specialized educationadapted to the health sector. Policy-makers, analysts and managers need to havea clear understanding of what determines the health status of individuals andpopulations, of the processes of effective and efficient production andutilization of health services, and how to ensure equity and high quality in thecare provided. Their training, while including a strong component of generalmanagement, hes to be adapted to the area of health. As such, it needs to bemuch more multi-disciplinary than the training usually offered through purebusiness oriented schools.

16. Another lesson of foreign experiences is that a proper balance betweenacademic and professional courses, and practical learning experiences is morelikely to produce effective policy-makers and managers than classroom teachingalone. Health managers need both analytical skills and intervention skills. Asleaders of their organization, they are expected to have good diagnosticcapacities and, above all, the skills to design and to implement strategies ofchange. They must be able to identify and understand existing problems as wellas anticipate future needs. In developing a new School of Health ServicesManagement, Hungary can benefit from a critical assessment of foreign trainingmodels, taking advantage of the lessons already learned by other countries.

17. Institutional Arrangements. Building one more time on foreign experiences,it can be argued that health services management and policy-making educationshould be of postgraduate level. It should be open to candidates who alreadypossess an undergraduate degree and preferably have some professional ormanagement experience in the health sector. No discrimination should be madebetween disciplines or professions. Management should be seen as requiringskills of a general nature, especially a high capacity to adapt to varyingsituations. It should not be seen as a mere application of set techniques ornormative standards, but as a continuous process of refining original responsesto complex and evolving problems. This needs a combination of good training,personal maturity, and an aptitude to organize and to lead, and not merely anacademic capacity.

18. As to which type of institution should take charge of health servicesmanagement education, there are a variety of options as illustrated by thesituation in other countries. There are independent schools, and departments

An example would be the criteria s*t by the Accrediting Commission of Educatian in Ebolth 8ervieesAdinlistration (ACSESA); in North America, nearly 100 institutions offer accredited prosram andhave tormed the Association of University Programs in Health Administration (AWUSA).

- 94 - 4

attached to other schools (business schools, schools of public health, facultiesof medicine, schools of public administration and, in some cases, programs only,with no departmental status).

19. Since health services management is a new field in Hungary, it would haveto establish its identity and credibility rapidly, if it is to have a significantimpact on the health sector. Consequently, it would be preferable to develop itas an institution which has the independence and the autonomy to organize itselfalong original lines and not depend, for its development, on the approbation ofauthorities concerned with other priorities. Even as an independent institution,it should, however, abide by high university standards, particularly in the caseof the qualifications of the teaching staff, and the quality of teaching andlearning activities.

20. At present, a number of institutions could be candidates to take charge ofhealth services management education in Hungary. In the field of medicaleducation, there is the Postgraduate Medical University, in Budapest, whichcurrently awards postgraduate degrees and diplomas in various fields related topublic health. Also interested in entering the field of management are the fourmedical universities (Semmelweis, Debrecen, Pecs, Szeged), which at present donot have the authority to grant postgraduate degrees. There are also non-medicalinstitutions, such as the University of Economic Sciences of Budapest, which hassome of its components already involved in management training (Irstitute forPostgraduate Studies in Economics, Management Development Center), and is alsointerested in expaniding its activities in the field of health services. Noinstitution, however, can mobilize the whole range of coursework needed in healthservices management education, which makes its development in a single medicalor non-medical university difficult. An alternative would be to develop acollaborative venture between institutions with complementary resources.

21. Other possible institutional arrangements are offered by the proposedcreation of a School of Public Health in Budapest which could have a jointprogram in health services management. The School would be independent andmanaged by a consortium of medical universities and public health institutions.It could: a) offer programs only; b) create a department in health servicesmanagement; or c) become a School of Public Health and Health ServicesManagement.

22. These options have already been discussed by interested parties, includingthe MOW, and preference has been expressed for the creation of an independentSchool of Health Services Management with close links to the proposed School ofPublic Health. Efforts would be made to avoid duplication of services, toencourage sharing of resources such as teaching materials and library services.It has also been decided that the School of Health Services Management would belocated in Budapest and attached to Semmelweis Medical University as anadministratively and financially autonomous school, like the School of PublicHealth; it would be run by a Management Board where the other medicaluniversities and the University of Economic Sciences would be represented. Thisarrangement would be consistent with the objectives of guaranteeing autonomy ofdevelopment and identity building, as well as building on available resources and

- 95 - ANNEX 4

avoiding waste.

23. Target-PopDulations. There are management training needs at all levels ofthe health care delivery system. It would not be possible to attend to all theidentified needs at the same time; choices have to be made between concentratingtraining efforts on a small minority of top leaders, at one end of the spectrum,or trying to give a little training to every one, at the other end. Given thelack of experience and resources, investments in a limited range and high qualityeducation, rather than in many simultaneous initiatives, lowers the risk ofdilution. Such an option would give priority to the training of r3neral managersfor top positions in health institutions, focussing on the development of skillsneeded to be effective at the strategic decision-making level. It assumes thatleadership has a ripple effect on other managers. This option would also addressthe needs of practicing managers, as well as those of future managers through on-site training. In other countries, health institutions often have short-termtraining programs for their own staff, using outside consultants.

C. DETAILED PROJECT DESCRIPTION

24. The creation of a School of Health Services Management is proposed as ameans of responding to the evolving needs of the health sector. Raising thequality of manager training would lead to more efficiency in the use of healthcare resources and thereby increase the impact of health services on the healthstatus of the community. The School would undertake training activities at thepostgraduate level, and develop continuing education programs. It would have aresearch program and eventually offer a PhD. While being an autonomous andfinancially independent school attached to Semmelweis Medical University(Budapest), and submitting to university standards, the School of Health ServicesManagement would be a joint and collaborative venture of an array of institutionsfrom Budapest and from the other major centers. Autonomy is required to developa strong identity and a new management culture to establish the credibility oftrained managers as quickly as possible. Collaboration would be particularlyclose with the new School of Public Health with which it would be possible toshare resources of various kinds.

Phasing During Project Preparation (1992) and Implementation (1993-99)

25. Project Pregaration 1992

Finalizing of plans according to the new legal environment.

Identify building and equipment needs for school of health servicesmanagement. (The Semmelweis Medical University would provide buildingsfor the School adjacent to the main teaching facilities. The buildingswould need renovation).

- 96 - ANNEX 4

The participating universities must agree on:

(a) the management structure of the School and appointment of aproject steering committee comprising representatives of theparticipating universities; and

(b) the formal link between the School and the Seumelweis MedicalUniversity (procedures for official recognition, awarding ofdegrees).

Define a selection procedure for teaching staff by public competition andproceed to selection, including shared appointments.

Identify training needs of teaching staff (language preparation, academictraining, pedagogical development) in consultation with the School ofPublic Health.

Plan training program for staff development.

26. Project ImRlementation 1993 - Year one

Institutional Development

Creation of the School of Health Services Management (SHSM);Refurbishment of school buildings and facilities;Appointment of management board of the School by the participatinguniversities;Set up advisory board;Make initial teaching appointments:

- full-time;- part-time;- shared appointments;

Development of support infrastructure:- administration;- library services;- computing services;

Buy support equipments;Library development /books, journals, databases.

Postgraduate Nac Program

Development of curricula and teaching materials;Training of teaching staff:

- 2 PhD programs' begin abroad;

PM program Iclude attendnce to one scientific conference pox yer

- 97 - AN= 4

- 3 short-term fellowships7 abroad;- one-week seminar on teaching methods for full-time and part-time staff;

Buy teaching e.quipment and basic equipments for teaching staff;Select first cohort of 15 students.

Continuing Education

Identify needs and priorities by consultation.Develop short-term programs for priority target groups;Offer three continuing education sessions (duration to bedetermined). Sessions would be offered on a regional basis.

Research Infrastructure

Books, computers, software, databases for teachers;Two-week seminar on research project preparation.

27. Project ImRlementation 1994 - Year two

Institutional D tvelopment

official opening of the SHSM;Library davelopment /books, journals, databases.

Post-graduate MSc Program

Development of curricula and teaching materials;Obtain university approval for courses and examinations;Initiate MSc course: cohort of 15 students;Training the teaching staff:

- 2 PhD programs begin abroad;- 2 PhD programs continue abroad;- 3 short-term fellowships abroad;- one-week seminar on teaching methods for full-time and part-time staff;

Development of a residency program: objectives, modalities,evaluation;Selection and training of practitioners to participate in thesupervision of residencies.

Continuing Education

Offer six continuing education sessions (duration to be determined).Sessions would be offered on a regional basis.

2/ Each felloahip includes attendance to mne scientific conference per year.

- 98 - AMEX 4

Research Infrastructure

Books, computers, software, databases for teachers;Two-week seminar on research in institutional development.

28. Project Implementation 1995 - Year three

Institutional Development

Library development /books, journals, databases.

Postgraduate NSc Program

Development of curricula and teaching materials;First cohort continue, second cohort selected and begin program;Training the teaching staff:

- 2 PhD programs begin abroad;- 2 PhD programs continue abroad;- 2 PhD programs continue in Hungary';- 3 short-term fellowships abroad;- one-week seminar on teaching methods for full-time and part-time staff;

Training of practitioners who supervise residencies;

Continuing Education

Offer six continuing education sessions (duration to be determined).Sessions would be offered on a regional basis.

Research Infrastructure

Books, computers, software, databases for teachers;Two-wer..c seminar on research on managers' traini.ng needs assessment.

29. Project Implementation 1996 - Year four

Institutional Development

Library development /books, journals, databases;Evaluation of first three years of project.

Postgraduate MSc Program

Development of curricula and teaching materials;First cohort graduate, second cohort continue and third cohort beginprogram;

j( Includes one month abroad to work with PhD supervisor and attend a scientific conference.

-99 - ANNEX 4

Training the teaching staff: 2 PhD programs begin abroad;2 PhD programs continue abroad;

- 2 PhD programs continue in Hungary;- 2 PhD programs finish;- 3 short-term fellowships abroad;- one-week seminar on teaching methods for full-time and part-time staff;

Training of practitioners who supervise residencies;

Continuing Education, Reform Supporting Courses

Offer six continuing education sessions (duration to be determined).Sessions would be offered on a regional basis.

Research Infrastructure

Books, computers, software, databases for teachers;Two-week seminar on qualitative research methods in management.

Other

First national conference (two days) on health services managementin Hungary (to coincide with graduation of first cohort of Masters'candidates).

30. Project Implementation 1997 - Year five

Institutional Development

Library development /books, journals, databases;Second evaluation of project.

Postgraduate MSc Program

Development of curricula and teaching materials;Second cohort graduate, third cohort continue and fourth cohortbegin program;Training the teaching staff:

- 2 PhD programs continue abroad;- 2 PhD programs continue in Hungary;- 2 PhD programs finish;- 3 short-term fellowships abroad;- one-week seminar on teaching methods for full-time andpart-time staff;

Training of practitioners who supervise residencies;

Continuing Education, Reform Supporting Courses

Offer six continuing education sessions (duration to be determined).Sessions would be offered on a regional basis.

- 100 -

Research Infrastructure

Books, computers, software, databases for teachers;Two-week seminar on evaluation methods in management.

Other

Second national conference (two days) on health services managementin Hungary.

31. Project Implementation 1998 - Year six

Institutional Development

Library development /books, journals, databases.

Postgraduate NMc Progrsa

Development of curricula and teaching materials;Third cohort graduate, fourth cohort cont 4 nue and fifth cohort beginprogram;Training the teaching staff:

- 2 PhD programs continue abroad;2 2 PhD programs continue in Hungary;

- 2 PhD programs finish;- one-week seminar on teaching methods for full-time and part-time staff;

Training of practitioners who supervise residencies.

Continuing Education

Offer six continuing education sessions (duration to be determined).Sessions would be offered on a regional basis.

Research Infrastructure

Books, computers, software, databases for teachers.

Other

Third national conference (two days) on health services managementin Hungary.

32. Project Imolementation 1999 - Year seven

Institutional development:

Library development /books, journals, databases;Final evaluation of project (end of year).

- 101 - AM 4

Postgraduate NSc Program

Development of curriculum and teaching materials;Fourth cohort graduate fifth cohort continue and sixth cohort beginprogram;

Training the teaching staff:- 2 PhD programs continue in Hungary;- 2 PhD programs finish;- one-week seminar on teaching methods for tull-time and part-time staff;

Training of practitioners who supervise residencies.

Continuing Education, Reform Supporting Courses

Offer six continuing education sessions (duration to be determined).Sessions would be offered on a regional basis.

Research Infrastructure

Books, computers, software, databases for teachers.

Other

Fourth national conference (two days) on health services managementin Hungary.

XluPmentti2n Arrangements

33. The following steps have been or would be taken to secure a successfulimplementation of the School of Health Services Management:

(a) Proposed legislation on higher education which has been presented toParliament would grant universities:

- administrative autonomy;- the right to establish schools and institutes;- the right to award postgraduate diplomas and degrees;

(b) Policy statement establishing a career pattern for health servicesmanagers. Cooperation with the Health Services Higher EducationProfessional Committee EFSZB, the Ministerial advisory body onissues of higher education would be needed.

(c) Measures will be taken to give administrative and financial autonomyto the School.

- 102 - ABU 4

(d) Formal agreement with the new School of Public health regarding theshared use of resources to avoid wasteful duplication.

(e) Alternative solutions to establish legal frameworks for the Schoolin case the legislation for higher education is delay-d.

Outputs

34. School of Health Services Management created with staff of eight full-timeand twelve part-time teachers, the latter employed through joint appointment withother institutions, with support staff, library and computer facilities in itsown buildings.

Eighit teachers trained at PhD level (six VhD completed, two with one yearto go).

Twelve teachers trained in a specialized area (short-term fellowships).

Network of residency supervisors established; seven training sessionsoffered.

Masters program curriculum and teaching material corresponding tointernational standards.

Four cohorts of fifteen Masters' level students graduated; one othercoh ,rt of fifteen would have done the first year of their program.

Continuing education program and teaching material developed.

Forty sessions of continuing education of up to two weeks duration; 800persons reached.

Research infrastructure created; research reports and articles published.

Four two-day national conferences on health services management.

- 103 - ANNEX 5

REPUBLIC NP HUNGARY

HEALTH SERVICES ANp MANAGEMNTQ PROJECT

Statistical Annex

A. General Country DataYear

Population (millions) 10.3 1992Area (km in thousaads) 93.0 1992Population Density (per kW2) 111.1 1992GDP Per Capita (US$) 2780 1990

B. Pouulation and Health

Annual Rate Of Population Growth (X) -0.02 1991Urban Pcpulation (X of total) 62.1 1992Population Age Structure

0-14 Years (X) 19.4 199215-64 Years (X) 67.0 199265(+) Years (X) 13.6 1992

Crude Birth Rate (per 1,000 population) 12.2 1991Total Fertility Rate 1.84 1991Babies Born With Low Birth Weight (X) 9.2 1991Crude Death Rate (per 1,000 population) 14.1 1991Life Expectancy At Birth:

- Feiwle 73.7 1990- Male 65.1 1990

Infant Mortality Rate Per 1,000 Live Births 15.1 1991- National Average

Mortality per 10,000 from:circulatory diseases 73.7 1990cancer 30.1 1990Percent change in mortality 1970-87England 22X decreaseW. Germany 271 decreaseUnited States 261 decreaseHungary 17X increasePercent change in heart disease mortality, 1970-87England 151 decreaseW. Germany 131 decreaseUnited States 491 decreaseHungary 421 incragse

-104 - muEL 5

C. Health Sectgr Resgrce

Total Beds (000s)Acute 73.9 1990Chronic 28.1 1990

Beds per 10000 populationAcute 71.4 1990Chronic 27.1 1990

Average Length-of-Stay (Days)Acute 9.9 1990Chronic 32.2 1990

Occupancy Rates (X)Acute 74.9Z 1990Chronic 84.6X 1990

Total days of hospitalization per 10,000 population 2,759.5 1990Discharges per 10000 population 217.9 1990

D. ActL Health Persgnnel

No. of active physicians (0008) 29.3 1990

Percent who are specialists (X) 76.3No. of physicians in hospitals (0008) 13.2Primary care districts (000.) 6.7Industry Districts (000s) 0.9Polyclinics & Other (000s) 8.5

No. of active physicians per 10,000 population 1990

In hospitals 12.7In primary care districts 6.5Total 28.3

No. of medical graduates (000) 0.9 1990

E. MUhgr ehrsonnel

No. of dentists (000s) 3.6 1990aTo. of nurses and midwives (000s) 53.8 1990No. of pharmacists (OOOs) 3.4 1990No. of pharmacies (000s) 1.5 1990

Source: Ministry of Public Welfare, 1991

- 105 - ANNEX a

F. OcCOUatiAl Distribution af Active Doctors

Hungary, December 1990(No.)

Prima CareCPs 4466Pediatricians 1456Maternal, child and adolescenthealth 619 6541

Industrial health servicesFactories 1244Railways 843 2087

Specialists (polyclinics) 5522 5522

lnstltutim- Hospitals 12828- Welfare institutions i90 13018

Other clinical serLvgs- Ambulance Service 136- Blood Bank 199- Other 153 488

Public health and epidemiology864 864

zfEduction- Universities 589- Other 112 601

Research 316 316

Administration 153 153

Other 83 83

TOTAL 29773

,Sgurc Ministry of Welfare, 1991

- 106 - ANNEX S

0. Measures VC Service Use

Selected Countries 1987-1990

Doctor DrugHospital Admissions Average consultations & expenditures as

Q1 CountrY days per per 100 stay home visits per 2 total healthl_________________ person population (days) person (annual) expenditure

Eastern EuropeHungary 2.8 21.8 12.7 9.4 27.7Poland 2.1 16.5 12.6 7.7 20.0CSFR 2.3 17.3 13.2 14.7 21.5

Western EuropeAustria 3.3 22.8 12.9 5.8 11.6Germany 3.5 21.5 16.6 11.5 20.7Denmark 1.8 20.9 8.6 5.2 9.3France 3.0 22.3 13.5 7.1 16.7

Other OECDAustralia 3.0 21.8 13.8 6.4 8.3Canada 2.0 14.5 13.2 6.6 11.6UK 2.0 15.9 15.0 4.5 11.3USA 1.3 13.8 9.3 5.3 8.3

OECD average 2.8 16.1 16.4 6.0 13.6

sources: Ministry of Welfare, 1991

H. International Comparisons

Selected Countries, 1987-19901/

Couny Hosgital beds for Practicing grofessionals ner 1000 All health Health1000 gopulation workers as exuenditure

X ag asXGDP________________ _____________ __________ populationAcute Total %Acute Doctor Dentist Pharmacist Qualified

Nurses

Eastern EuropeHungary 7.1 9.8 72 2.8 0.3 0.4 5.3 2.0 6.0Poland na 7.1 na 2.0 0.4 0.4 5.1 na 5.4CSFR na 12.2 na 3.7 0.5 0.4 6.8 2.1 5.8

Western EuropeAustria 6.4 l1.7 60 2.0 0.4 0.3 6.6 2.3 8.2Germany 7.4 10.9 68 2.9 0.6 0.6 5.0 2.7 8.2Denmark 4.8 6.1 94 2.7 0.5 0.3 6.0 na 6.3France 5.4 10.2 53 2.6 0.7 0.9 na 2.7 8.7Other OECDAustralia 5.2 9.8 53 2.1 0.4 0.6 10.2 2.9 7.7Canada 4.3 6.7 64 2.2 0.5 0.8 12.7 na 8.7UK na 6.5 na 1.4 0.4 na 4.3 2.3 5.9USA 3.7 4.9 76 _ 2.3 0.6 0.7 6.5 _ 3.1 11.8OECD average 5.1 9.2 55 2.3 na 0.6 na na 7.4

Sources: Ministry of Welfare, 1991

x1e/ Hun4azy 1.980, \u.t.ralia 1889-90,* moat. other coormtr1ea 1988. *

- 108 - ANNEX 5

I. Health Care Financing

1. Total Health Exoenditures. 1990 I/

Current Expenditures Ft. Billion ( lotall

PublicOutpatient primary care 9.78 7.9Outpatient specialist care 9.19 7.4In-patient care 39.02 31.5Ambulance services 2.08 1.4Public Health 2.26 1.8Other Health Services 2.54 2.0Pharmaceutical subsidies 27.56 22.3

Subtotal Public 97.54 79.2

PrivateOut of pocket expenses 19.00 / 15.4

Total Current ExDenditures 116.20 93.8

Capital Expenditures 7.62 6.1

Total Health Expenditures 123.82 100.0

Source: Ministry of Welfare and mission estimates.

1/ Excludes railroad, policy and military health expenditures.2/ Out-of-pocket cost of drugs, plus estimated value of gratuities.

Total expenditures as X of GDP 5.95 X

Total expenditures per person in:- Forints 11,957- US$ 193

- 109 - Anx 6

REPMBLIC OF HUNGARYHEAITH SERVICES AnD NAGENET PROJECT

Detailed Project Cost Estimtes(US$ thousand)

Unit Unit/ Physicalof Total Bass Costs Contingencies Escalated Cost TOTAL

Input Base Deseription of Inputs --------------------------- --------------- ----------------- PROJECTCost Local Foreign Total Local Foreign Local Foreign COST

-------------------------------- _-----------------_-------------__-----------__-_--------------_-----------------------

1. BELT SEVICKS

1.1 PublicEblt

1. 11 Strenatheninu of the NPMC

m/month 8.0 ST Fellow(Z):Study tour 0 252 252 0 13 0 311 311m/month 4.0 LT FellowtS)Mc program 0 288 288 0 14 0 336 336m/month 15.0 LTcersBL 0 540 540 0 27 0 629 629r/month 18.0 SToonsUL 0 450 450 0 23 0 551 551m/month 12.0 SToonaML 0 264 264 0 13 0 319 319m/month 8.0 STconaLL 0 1152 1152 0 58 0 1343 1343

annual 2000.0 Closing the Gap Progran 0 14000 14000 0 700 0 17430 17430package 3.8 PC386 Hardware/Peripherala 11 27 38 1 3 13 32 45

annual 0.3 Compu O&M 8 8 15 1 1 10 10 20package 2.5 Database Msna8mgent Software 3 9 13 0 1 4 11 15annual 0.2 software license/upgrade 1 4 5 0 0 2 5 7

package 1.3 LAN Software 1 2 3 0 0 1 2 3annual 0.1 Softwre license/upgrade 0 1 1 0 0 0 1 1

package 12.6 Office Equipeent 4 9 13 0 1 4 11 1Sannual 0.6 Equip OM 2 1 3 0 0 2 2 4

package 12.6 Furniture: 12 1 13 1 0 14 1 15S Spread 103.9 Refurbish PMPU office space 06 8 104 10 1 115 9 124m/month 0.7 Increm Salary:Profess staff 393 0 393 20 0 508 0 508rnmonth 0.3 Increm Salary:Support staff 94 0 94 5 0 121 0 121

annual 100.0 Nonsal Oper Costs 557 23 580 56 2 735 30 765

1.12 Chronic Disease Primarv Prevention

m/month 6.0 ST Fell:cumunity intervtn prog 0 48 48 0 2 0 56 56m/rnonth 18.0 STconsHLcommurity intervention 0 81 81 0 4 0 98 O8M/month 15.0 LTconsBL:corourity intervention 0 1170 1170 0 59 0 1458 1458S Spread 1650.0 Study:Community damonatration 0 1650 1650 0 83 0 2227 2227S Spread 350 0 Anti-smoking program 0 350 350 0 18 0 432 432package 3.8 PC386 Hardware/Peripherals 2 5 8 0 1 3 6 9

annual 0.3 Compu OIM 2 2 4 0 0 2 2 5package 2.5 Database management Software 1 4 5 0 0 2 4 6

annual 0.2 PC Software licenae/upgrade 1 2 2 0 0 1 2 3package 12.6 Office Bqpipment 7 18 25 1 2 9 20 29annual 0.6 Equip C&M 4 3 6 0 0 6 4 10

m/month 0.3 Inrem Salary(10):Interv team 260 0 260 13 0 325 0 325X Spread 100.0 Nonsal Oper Costs 96 4 100 10 0 123 5 128

-------------------------------------------------------- _--------------__-__-__-----------__-_------__-__--------------

- 110 - Annex

REPUBLIC OF HUlNAkYNEALE SERVICES AnD NfAiNGENT PlOJECT

Detailed Project Cost Estimates(US$ thousand)

Unit Unit/ Physicalof Total Base Costs Contingencies Escalated Cost TOTAL

Input Base Description of Inputs --------------------------- --------------- ----------------- PROJECTCost Local Foreign Total Local Foreign Local Foreign COST

--------------------------------------------------------- __------------------------------------------------------------

1.13 Chronic Disease Secondary Prevention

m/month 6.0 ST Fell:Meamog/hyperten/oyto 0 39 39 0 2 0 44 44annual 50.0 Training:cytology 200 0 200 10 0 233 0 233annual 50.0 Training:mammography 100 0 100 5 0 114 0 114

m/month 18.0 STconsHL:mammography 0 63 63 0 3 0 78 78m/month 18.0 STconsHL:analyst/cancer regist 0 648 648 0 32 0 755 755m/month 12.0 STconsdL-evaluation 3 progras 0 432 432 0 22 0 543 543package 3.8 PC386 Hardware/Peripherals 43 104 147 4 10 53 128 181annual 0.3 Compu O&M 25 25 51 3 3 35 34 69

package 1.3 PC Software 13 36 49 1 4 16 45 60annual 0.1 PC Software license/upgrade 4 13 17 0 1 6 17 23

package 10.7 Medical Equip:Endoscopea 6 47 54 1 5 8 57 64annual 0.5 Equip O&M 8 6 13 1 1 10 8 18

package 80.3 Medical Equip:Mammographic unit 38 284 321 4 28 48 360 407annual 4.0 Equip O&H 33 23 56 3 2 45 32 77

X Spread 100.0 Health education messages 0 100 100 0 5 0 117 117r/month 1.0 Incrsm Salary:4 mammog unit mgr 264 0 264 13 0 334 0 334m/month 0.3 Incren Salary:2RNs 8s 4 mamw uni 176 0 176 9 0 223 0 223

annual 200.0 Nonsal Operational costs 864 36 900 86 4 1167 48 1215

1.14 School Health

m/month 6.0 ST Fell:health education 0 60 60 0 3 0 72 72m/month 5,0 LTconsLL:Pro8ram manaser 0 420 420 0 21 0 S19 519

annual 20.0 Competitive Health promo pros 0 140 140 0 7 0 173 173package 50.0 Health education materials 279 21 300 28 2 367 28 395annual 30.0 In-country train/teachers/MJD 30 0 30 2 0 259 0 259

package 3.8 PC386 Hardware/Peripherals 2 5 8 0 1 3 6 9annual 0.3 Compu OM 2 2 4 0 0 2 2 5

package 2.5 Database management software 1 4 5 0 0 2 4 6annual 0.2 Software license/upgrade 1 2 2 0 0 1 2 3

m/month 1.0 Increm Salary:Health educator 84 0 84 4 0 104 0 104m/month 0.3 Increm Salary:support staff 28 0 28 1 0 35 0 35

1.15 Huntarian Health Surveys

m/month 6.0 ST Fell:Survey planning 0 9 9 0 0 0 10 10m/month 15.0 LTconsHL:heslth surveys 0 360 360 0 18 0 412 412m/month 18.0 STconsHL:survey planning 0 18 18 0 1 0 20 20package 3.8 PC386 EardwaretPeripherals 4 1t 15 0 1 5 12 17

annual 0.3 Compu O&M 4 4 7 0 0 5 5 10package 2.5 Database management software 3 7 10 0 1 3 9 12

annual 0.2 Software license/upgrade 1 4 5 0 0 2 5 6X Spread 4155.0 Study:Health Surveys 0 4155 4155 0 208 0 5043 5043

-------------------------------------------------------------- _----___-_-----__----------------------------------------

subtotal: 3769 27451 31220 295 1411 5079 33938 39017…----------------------------------------------------------------__----------__----------------------------------------

- 111 - Annex

REPUBLIC OF HUNQARYBEALTH SERVICES AND NANAGEMNT PROJECT

Detailed Project Cost Estimates(US$ thousand)

Unit Unit/ Physicalof Total Base Costs Contingencies Escalated Cost TOTAL

Input Base Description of Inputs --------------------------- --------------- ----------------- PROJECTCost Local Foreign Total Local Foreign Local Foreign COST

---------------------- _-----------------------------------------__---------_-__----------------------------------------

1.2 Institutional Care

1.21 Stroke Program

max/outh 18.0 SToonsHL:equipment specialist 0 36 36 0 2 0 41 41package 920.7 Modical Equip.CT scanners 647 4877 5524 65 488 775 5842 6616

annual 46.0 Eguip OM 804 577 1381 80 58 1070 775 1853S Spread 120.0 Refurbish 6 stroke facil 111 9 120 11 1 133 11 144X Spread 18.0 Bldg engineeringS/onst superv 18 0 18 1 0 20 0 20

unit 75.0 Nonsal Oper Costs:CT scan suppl 0 0 0 0 0 0 0 0

1.22 Cardiovasoular Diseases

r/month 18.0 STconsHL:equipment specialist 0 36 36 0 2 0 41 41X Spread 100.0 Refurbish 5 cardiovac centers 93 7 100 9 1 111 9 120X Spread 15.0 Bldg engineering/const superv 15 0 1S 1 0 17 0 17package 1685.2 Med Equip:Hungar Inst Cardiolos 197 1488 1685 20 149 236 1782 2018

annual 42.1 Equip 0&M 123 88 211 12 9 165 118 283package 1685.2 Med Equip:Semuelweis Med School 197 1488 1665 20 149 238 1782 2018

annual 42.1 Equip 0UM 123 88 211 12 9 165 118 283package 1665.2 Med Eqyip:B.P,Postgrad Med SchL 197 1488 168S 20 149 236 1782 2018annual 42.1 Equip O&M 123 88 211 12 9 165 118 283

package 346.9 Med Equip:Debrecen Medical Scho 41 306 347 4 31 49 367 415annual 8.7 Equip O&M 25 18 43 3 2 34 24 58

package 1685.2 Med Equip:Szoged Medical school 197 1488 1685 20 149 236 1782 2018annuaL 42.1 Equip O& 123 88 211 12 9 165 118 283package 623.4 Med Equip:Szeged Medical school 73 550 623 7 55 87 659 747annual 15.6 Equip O&M 45 33 78 5 3 61 44 105unit 623.4 lonal Oper Costs 2993 124 3117 299 12 4016 167 4183

1.23 Physical Rehabilitation

r/month 18.0 STconsHL:equipnent specialist 0 36 36 0 2 0 41 41X Spread 3246.8 Conatruction: 3006 241 3247 301 24 3670 294 3964Z Spread 64.9 Build O&M 281 12 292 28 1 380 16 395X Spread 194.8 Bldg design/oonstrctn superv 195 0 195 10 0 224 0 224package 448.5 ICU equip:Natl Instit Med Rehab 52 394 447 S 39 65 490 555annual 11.2 Eguip O&M 26 19 45 3 2 36 26 61

package 291.2 Med equip:Natl Instit Med Rehab 34 257 291 3 26 42 320 362annual 7.3 Equip O&M 17 12 29 2 1 23 17 40unit 756.4 Nonsal Oper Costs:NIMR ICU 1121 2292 3413 112 229 1516 3101 4617

package 193.8 Med equip:County locmaot rehab 23 171 194 2 17 28 213 241annual 4.8 Equip O&M 11 8 19 1 1 15 11 26

package 794.4 Med equip:Balatonfured State Ho 93 701 794 9 70 116 872 988annual 19.9 Equip O" 46 33 79 5 3 63 45 109

package 1848.8 Med equip:other cardi rehab de 216 1631 1847 22 163 269 2028 2297annual 46.2 Equip O& 107 77 185 11 8 147 106 252unit 280.0 Noap Rehab Ctrs:Med consumab/su 1344 56 1400 134 6 1804 75 1879

---------------------------------------------------- ,-------12717---18816---31535---1260--1876---1638----23233---39616-

8dbtabal: 127l7 18818 31535 11260 1876 16383 23233 39616

- 112 - Annex 6

RlPUlJLIC OF HUNGARYHUL SWIMCE AND NAGNA=T PROJECT

Detailed Project Cost Estimates(US$ thousand)

Unit unit/ Pbhsicalof Total Base Costs Contingencies Esoalated Cost TOTAL

Input Base Description of Inputs --------------------------- --------------- ---------------- PROJECTCost Local Foreign Total Local Foreign Local Foreign COST

------ __------------_---_---------------------------------------__-----------__----------------------------------------

2. MMC MrL 5 JD MhU MR

2.1. Ptb6i WeaUlh !nd _Nsam TrmI.

2.11 School of -Beat stervices HbnaRmeent

n/month 6.0 ST Fel: 0 72 72 0 4 0 84 84r/month 4.0 LT FeU:8 PhD program 0 1152 1152 0 58 0 1369 1369S Spread 150.0 Curric/instrctnal matls dev 0 150 1S0 0 8 0 177 177r/month 18.0 STconsVL:progran evaluation 0 90 90 0 5 0 115 1152 Spread 100.0 In-country traininelpractitners 100 0 100 5 0 128 0 126Vackage 3.8 10386 6rdwere/Peripberals 33 80 113 3 8 41 9S 140

anual. 0.3 CCmpuO & 14 14 28 1 1 19 19 38package 25.1 File Server:1 GB storage 15 35 50 1 4 18 44 63

annual 2.0 Capu OM 6 6 12 1 1 8 8 16package 2.5 Database management software 10 28 38 1 3 12 35 47annual 0.2 Software license/upgrade 3 9 12 0 1 4 13 17

package 1.3 LN software 1 2 3 0 0 1 2 3annual 0.1 Software liense/upurade 0 1 1 0 0 0 1 1

I Spread 1087.0 Construction: eslth 4gmt School 1006 81 1087 101 8 1229 98 1327I Spread 21.7 Build aM 94 4 98 9 0 127 5 132X Spread 65.2 Bldg design/oenst supervision 65 0 65 3 0 75 0 75package 50.0 Training/AV equipment 15 35 50 1 4 18 44 62

annual 2.5 Equip 6h4 a 4 10 1 0 8 5 14package 12.6 Office Equip nt 4 9 13 0 1 5 11 16

annual 0. 8 quip OM 1 1 3 0 0 2 1 3Z Spread 108.7 Sehool furniture 100 9 109 10 1 124 11 135package 0.7 Computer desk 21 2 22 2 0 26 2 28package 100.0 Books/Tech Journals 93 7 100 9 1 107 8 115annual 10.7 Subscription 60 5 64 6 0 79 6 85

ux/month 1.0 Incren Salary:8 F/time profess 432 0 432 22 0 558 0 558annual 60.0 Inurem Salazy:Part time faculty 300 0 300 15 0 383 0 383

m/month 0.3 lucrem Salaxy:15 residen superv 240 0 240 12 0 314 0 314m/month 1.5 lunre Sal8azy:Director 117 0 11t 6 0 146 0 146m/mcuth 0.3 Incram Salarrysupport/sec pool 136 0 136 7 0 175 0 175

annual 120.0 Nonsal Oper Costs 576 24 600 58 2 770 32 802

-----------------------. _---------------------------------_------------__-----__------------------_-------------------

- 113 - Annex 6

EPUBLIC OF NGARYHEALTH SERVICES AND NANAOMT PROJECT

Detailed Project Cost Kstimates(US$ thousand)

Unit Unit/ Physicalof Total Base Costs Contingencies Escalated Cost TOTAL

Input Base Description of Inputs --------------------------- --------------- ----------------- PROJECTCost Local Foreign Total Local Foreign Local Foreign COST

--------------------------------------- _------------------------__---_-------__----------------------------------------

2.12 8chool of Public Health

m/month 6.0 8S Fell:study visits 0 60 60 0 3 0 68 66m/month 4.0 LT Fe11:25 M8c courses 0 1296 1296 0 65 0 1592 1592m/month 4.0 LT Fell:PbD courses 0 576 576 0 29 0 697 697m/month 4.0 LT Fell:EI8 feLlowships 0 288 288 0 14 0 349 349

annual 20.0 LT Fell:TEMPUS supported Mc 0 100 100 0 5 0 114 114r/month 15.0 LTconsBL:direct FETP 0 285 285 0 14 0 329 329n/month 18.0 SconsHL: school curr planning 0 234 234 0 12 0 275 275I Spread 140.0 Develop teaching modules 0 140 140 0 7 0 164 164X Spread 194.8 Refurbish school facilities 160 14 19S 18 1 216 17 2333 Spread 3.9 Build O&M 19 1 19 2 0 25 1 262 Spread 19.5 Bldg engineering/conat superv 19 0 19 1 0 22 0 22X Spread 23 School furniture 22 2 23 2 0 27 2 29package 50.0 Training/AV/office equipment 15 35 50 1 4 18 44 62

annual 2.5 Euip O&M 6 4 10 1 0 8 6 14package 100.0 Library Books/software 93 7 100 9 1 111 8 120

annual 10.7 Annual subscriptions 50 4 54 S 0 67 5 72package 3.8 PC386 Bsrdware/Peripherals 24 59 83 2 6 30 73 103annual 0.3 Compu O&M 13 13 27 1 1 18 16 36

package 2.5 Database management software 14 41 55 1 4 18 51 69annual 0.2 Software license/upgrade 5 13 18 0 1 6 18 24

rnmonth 1.0 Increm Salary:6 F/time faculty 456 0 456 23 0 585 0 585r/m0onth 1.5 Increm Salary:Director 117 0 117 6 0 146 0 146r/month 0.3 Incrum Salary:4 admin staff 82 0 82 4 0 105 0 10S

annual 100.0 Nonsal Oper Costs 461 19 480 46 2 619 26 645…---------------------------------------------------------------------__-----__------------------------------------_---

Subtotal: 5025 5010 10035 399 279 6396 6047 12443…-----------------------------------------------------------------__---------__----------------------------------------

- 114 - Annex 6

REPUBLIC OF HUNGARYHUALMH SERVICES AND ANEMENT PROJECT

Detailed Project Cost Estimates(US$ thousand)

Unit Unit/ Pysicalof Total Base Costs Contingencies Escalated Cost TOTAL

Input Base Description of Inputs --------------------------- --------------- ----------------- PROJECTCost Local Foreign Total Local Foreign Local Foreign COST

------------------------------------------------------------ _-----------------------------------------------------------

2.2 tInagenet S=uort Svat

2.21 MOW Comnutina Center (Szekszard)

m/month 18.0 STcousUL:Applic system design 0 108 108 0 5 0 123 123m/month 15.0 LTconsi! :File conversion 0 180 180 0 9 0 206 206m/month 18.0 STconsBL:Computer programmer tr 0 108 108 0 5 0 123 123m/month 6.0 ST FeUl:observation tour 0 15 1S 0 1 0 17 17package 400.0 Minicomputers (2) dual 235 565 800 23 57 281 677 958annual 32.0 Compu O0M 161 159 320 16 16 216 214 429

package 800.0 Database management software 207 593 800 21 59 248 710 958annual 64.0 Software license/upgrade 83 237 320 8 24 111 318 429

package 150.0 Operating systems/utilities sof 39 111 1S0 4 11 47 133 180annual 12.0 Software license/upgrade 16 44 60 2 4 21 60 81

2.22 Management Information Sunnort Systems for hosvitals

Phase 1: Pilot Hospitals (5)m/month 18.0 STconsBL:Strategic systems plan 0 36 36 0 2 0 40 40m/month 18.0 STconsEL:Minimal data set 0 18 18 0 1 0 20 20m/month 18.0 STconsBL:Reimburaement 0 36 36 0 2 0 40 40m/month 18.0 STconsBL:MIS market survey 0 18 18 0 1 0 20 20m/month 18.0 STconsBL:Data for external inst 0 36 36 0 2 0 40 40m/month 18.0 STcoasBL:System design 0 108 108 0 5 0 119 119rn/month 18.0 STaonsBL:FS selectn/modificatio 0 18 18 0 1 0 20 20rn/month 18.0 STcons9L:Procurement/bid eval 0 18 18 0 1 0 20 20Z Spread 267.0 TA counterparts:applic devel 267 0 267 13 0 301 0 301rn/month 6.0 ST Fell:overseas training 0 288 288 0 14 0 333 333S Spread 94.0 In-country training:users 0 94 94 0 S 0 107 107

unit 10.0 Refurbish pilot sites 46 4 50 5 0 55 4 60package 3.8 PC386 Hardware/Periph(25/hosp) 138 333 471 14 33 166 399 564

annual 0.3 Compu O& 95 94 188 9 9 127 126 253package 2.5 PC286 Rardware/Periph(25/hosp) 92 222 314 9 22 110 266 376annual 0.2 Compu O( 63 63 126 6 6 85 84 169

package 25.1 File servers/lGB storge(5/hoap) 185 444 628 18 44 221 531 752annual 2.0 Compu O6M 126 125 251 13 13 169 168 337

package 12.6 Optical disks (2/hosp) 37 89 126 4 9 44 106 150annual 1.0 Compu OSm 25 25 50 3 3 34 34 67

package 50.3 NEXT workstation (1/hosp) 74 177 251 7 18 88 213 301annual 4.0 Compu OW 50 50 101 5 5 68 67 135

package 5.0 Palmtop terminal (4/hosp) 30 71 101 3 7 35 85 120annual 0.4 Compu O&G 20 20 40 2 2 27 27 54

package 2.5 Database mgment software(S/hosp 16 47 63 2 S 20 56 75annual 0.2 Software license/upgrade 7 19 25 1 2 9 25 34

package 1.3 LAN software(5/hosp) 8 23 31 1 2 10 28 38annual 0.1 Software license/upgrade 3 9 13 0 1 4 13 17unit 50.0 LAN cables 15 35 S0 1 4 18 42 60

package 30.0 Computer equipment installation 18 12 30 2 1 22 14 36unit 0.7 Computer furniture 193 17 210 19 2 232 20 252

package 12.6 Office Equipment 18 44 63 2 4 22 53 75annual 0.6 Equip O&M 9 7 16 1 1 12 9 21

m/month 1.0 Increm Salary:10 tech staff 480 0 480 24 0 570 0 570annual 51.9 Comunic Software license/upgra 67 192 260 7 19 90 258 349annual 51.9 llonsal Oper:comsunic charges 249 10 260 25 1 335 14 349

- 115 - Annex 6

REPUBLIC OF NGARYHEATH SILRVICES AND NAME=T PROJECT

Detailed Project Cost Estimates(US$ thousand)

unit Unit/ Physicalof Total Base Costs Contingencies Escalated Cost TOTAL

Input Base Description of Inputs --------------------------- --------------- ----------------- P-jJECTCost Local Foreign Total Local Foreign Local Foreign COST

Phase 2: Hospitals (20)m/month 5.0 LtconsLL:Install supp/managst 0 240 240 0 12 0 302 302=/month 5.0 LTconsLL:Install supp/data conv 0 120 120 0 6 0 145 145r/month 5.0 LTconsLL:Install supp/documenta 0 60 60 0 3 0 74 74z/month 8.0 STconsLL:Install supp/softwr cu 0 480 480 0 24 0 615 615Z Spread 60.0 Tn-country trainins:users 60 0 60 3 0 71 0 71package 3.8 PC386 Hardware/Periph(25/hosp) 554 1331 1885 55 133 688 1656 2344

annual 0.3 Compu O& 303 300 603 30 30 414 410 824package 2.5 PC286 Hardware/Periph(25/hosp) 369 887 1257 37 89 459 1104 1563

annual 0.2 Campu OWM 202 200 402 20 20 276 274 549package 25.1 File servers/lOB storge(5/hosp) 738 1775 2513 74 177 918 2208 3126

annual 2.0 Compu O0M 404 400 804 40 40 552 547 1099package 12.6 Optical disks (2/hosp) 185 444 628 18 44 229 552 781annual 1.0 Compu O&M 101 100 201 10 10 138 137 275

package 2.5 Database mgient software(5/hosp 82 233 315 8 23 102 290 392annual 0.2 Software license/upgrade 26 75 101 3 7 36 102 138

package 1.3 LAN software(5/hosp) 41 117 157 4 12 51 145 196annual 0.1 Software license/upgrade 13 37 50 1 4 18 51 69

package 100.0 Computer equipment installation 62 38 100 6 4 77 48 124unit 0.7 Computer furniture 709 61 770 71 6 882 76 958

Phase 3: Hospitals (135)3 Spread 202.5 In-country training:users 203 0 203 10 0 240 0 240package 3.8 PC386 Hardware/Periph(5/hosp) 747 1797 2544 75 180 965 2320 3285

annual 0.3 Compu OM 307 304 611 31 30 427 423 850package 25.1 File servers/lGB storge(I/hosp) 996 2396 3393 100 240 1286 3094 4380

annual 2.0 Compu O&M 409 405 814 41 41 569 564 1133package 2.5 Database n8ment software(1/hosp 88 252 340 9 25 114 325 439

annual 0.2 Software license/upgrade 21 60 82 2 6 29 84 114package 1.3 Finan Managmt applic saftware(l 44 126 170 4 13 57 163 219

annual 0.1 Software license/upgrade 11 30 41 1 3 15 42 57package 67.5 Computer equipment installation 42 26 68 4 3 54 34 87

unit 0.7 Computer furniture 522 45 567 52 5 674 58 732package 3.8 PC386 Hardwars/Perip(45 inst) 50 120 170 5 12 60 144 203

annual 0.3 Compu O&M 34 34 68 3 3 46 45 91package 2.5 Database management software 29 84 113 3 8 35 101 136

annual 0.2 Software license/upgrade 12 34 45 1 3 16 45 61unit 0.7 Computer furniture 29 3 32 3 3 35 3 38

_________________________________________--- 10__64__17537___28001___996__1655___ 13330___ 22157___ 35486_

8ubbo"4: 10464 1753t 28001 996 1655 13330 22157 35486------------------------------- _____--__-_-----_-------_____---_-__-----_----__----------------_-----------------------

- 116 - Annex 6

RKPUBLIC OF NUNGARY1ATH URVICESD 61DDSltNT PkOJACT

Detailed Project Cost Estimates(US$ tbousand)

Unit Uriit/ Physicalof Total Bsee Costs Contingencies Escalated Coat TOTAL

Input Base Description of Snputa --------------------------- --------------- ----------------- PROJECTCost Looal Foreign Totel Local Foreign Local Foreign COST

2.3 Pro1e$ t t blt

2.31 ProjeSt IlanagMent Unit

m/month 15.0 LTcusSL:ProJect Man4aent 0 1665 1665 0 83 0 1957 1957mn/month 6.0 8S FellOCbsermtion tour 0 36 36 0 2 0 40 40package 3.8 PC386 Hardwar./Peripherals 2 5 8 0 1 S 6 9

annual 0.3 CcWpu OH 2 2 4 0 0 2 2 5package 2.5 Database anagesment Software 1 4 S 0 0 2 4 6

annual 0.2 PC Software licease/upgrade 1 2 2 0 0 1 2 3package 12.6 Office Equipment 4 9 13 0 1 4 10 14

annual 0. 8qu±p OM 2 2 4 0 0 3 2 5annual 50.0 Fonsal Oper Costs 312 13 325 31 1 407 17 424

----------------------------------------------------------------- _----__-----__----------------------------------------

Subtotal: 324 1737 2061 32 89 422 2042 2463

2.4 Uiy -WA

2.41 Prenaration of Preivertment Studies

X Spread 2500.0 Prinvestment Study 0 2500 2500 0 125 0 2980 2980Z Spread 500.0 Feasib study for qualty contro 0 500 500 0 25 0 621 821

Subtetal.: 0 3000 3000 0 1S0 0 3601 3601

2UZAL RJE GQS: 32298 73554 105852 2983 5458 41609 91018 132627

- 117 - Am 7

R .ILIC °P HU RYHEALTH SIRVICES AV, NAN&9N=E PROJECT

Project Implementation Schedule

------Distribution of Quantitles ------ TotalType Unit -- ----- ----- ----- ----- ----- ----- Quantityof of Description Yrl Yr2 Yr3 Yr4 YrS Yr6 Yr7 of

Component Input Input Fiscal 1993 1994 1995 1996 1997 1998 1999 Inputs

1. BKU sms D

1. 1 Z Mlc h

1. 11 StrangthenSna of the SPEC

Fellowship m/month ST Fellow(2):Study tour 6 6 6 6 6 6 6 42Fellowship m)onth LT Fellow(6)MSc program 12 24 24 12 72Consultant mu/month LTconsBL 6 12 12 6 36Cosultant m/month STconsHL 4 4 4 4 3 3 3 25Consultant m/month STconsaL 4 4 4 4 2 2 2 22Consultant m/month SToonsLL 24 48 48 24 144Development annual Closing the Gap Program 0.5 1 1 1.5 1 1 1 7Computer packase PC386 Bardware/Peripherals 10 10

Maintenance annual Computer O&M 0 10 10 10 10 10Software package Database Management Software 5 5License annual Software licese/upgrade 0 5 5 5 5 5

Software package LAW Software 2 2License annual Software license/upgrade 0 2 2 2 2 2

Equipment package Office Equipment 1 1Maintenanoe annual Equipment O&M 0 1 1 1 1 1Furniture package Furniture for PHPU office 1 1Buildings X Spread Refurbish PEPU office space 100l 1002Salary m/month Inorm Salary:Profess staff 24 60 72 144 144 144 588Salary mo/month lacram Balary:Support staff 18 36 48 60 60 60 282

Recurrent annual Nonsalary Operational Costs 0.3 0.5 1 1 1 1 1 6

1.12 Chronic Disease Primary Prevention

Fellowahip u/month ST Fell oammonity intervtn prog 2 2 2 1 1 8Consultant m/month STcavsHL: *oawnity intervention 1 1 0.5 0.5 0.5 0.5 0.5 5Consultant u/month LTconeHL:community intervention 6 12 12 12 12 12 12 78Development Z Spread Study:cosmcnity demonstration 8S 172 172 171 172 172 172 108XDevelopment X Spread Anti-mocking prograr 141 141 142 142 142 142 142 1002Computer package PC386 Hardware/Peripherals 2 2

Maintenance annual Computer 08K 2 2 2 2 2 2Software package Database management Software 2 2License annual PC Software license/upgrade 2 2 2 2 2 2Equipment package Office Equipmet 2 2

Maintenance annual Equipment O&H 2 2 2 2 2 2Salary /mmonth Inorem Salary(10) :Interv team 60 120 120 120 120 120 120 780

Recurrent Z Spread Nonsalary Operational Costs 10 202 202 202 102 101 102 1002

- 118 - Annex 7

BUBLIC oP HUMATH EVICERS An NANAGE PROJEC?

Project Implementation Schedule

_-----Distribution of Quantities------ TotalType Unit --- ----- ----- ----- ----- ----- Quantityof of Description Yrl Yr2 Yr3 Yr4 YrS Yr6 Yr7 of

Component Input Input Fiscal 18993 1994 1985 1996 1997 19o8 1999 Inputs

1.13 Chronic Disease Secondarvy Prvention

Fellowship m/month ST Fell Fbmmog/hyperten/cyto 3.5 3 7Traininrg anual Training: cytology 1 1 1 1 4Training annual Training _aogrepthy 1 1 2

Consultant m/month STconsL:masmcography 0.5 0.5 0.5 0.5 0.5 0.5 0.5 4Consultant m/month STConsHL:analyst/cancer resist 6 12 12 6 36Consultant m/month STconsM:Levaluatior 3 progres 6 6 6 6 6 6 36Computer package 7C388 Hardware/Peripberala 2 10 25 2 39

Maintenance annual Computer OM 2 12 37 39 39 39Software package PC Software 2 10 25 2 39License annual PC Software licnse/upgrade 2 12 37 39 39 39

Equipment package Medical Equip:Endoscopes S 5Maintenance annual Equipment OWM 0 S 5 5 5 5Equipant package Medical Equip:Mammographic units 1 3 4

Maintenance annual Equipment O&M 0 1 1 4 4 4Development X Spread Health education messages 501 501 1001

Salary a/month Increm Salary:4 emog Unit m8r 12 12 48 48 48 48 48 264Salary m/month Incram Salary:2RNs 6 4 maw uni 24 24 96 96 96 96 96 528

Recurrent annual Nonsalary Operational Costs 0,25 0.25 1 1 1 1

1.14 School Baalth

Fellowship a/month ST Fell:health education 2 2 2 1 1 1 1 10Consultant a/month LTconsLL:Prograns manager 12 12 12 12 12 12 12 84Development annual Competitive Health promo prog 1 1 1 1 1 1 1 7Software package Health education materials 1 1 1 1 1 1 6Training annual ln-country train/teachers/eJD 1 1 1 1 1 1 1Computer package PC386 Hardware/Peripherals 2 2

Maintenance annual Computer O&M 2 2 2 2 2 2Software package Database manae8ment software 2 2License annual Software license/upgrade 2 2 2 2 2 2Salary a/month lncrom Salary:Health educator 12 12 12 12 12 12 12 84Salary a/mnth Increm salary:support Staff 12 12 12 12 12 12 12 84

1.15 Hunsaeian 8ealth Survenn

Fellowship m/month ST Fell:Surver planning 1 0.5 2Consultant a/month LTcons8L:health surveys 6 12 6 24Consultant a/month SToonsfL:survey planaing 1 1Computer package PC386 Hardware/Peripherals 4 4

Maintenance annual Computer O0M 4 4 4 4 4 4Software package Database management safttowe 4 4Lioense nnual Software Ulense/upreAde 4 4 4 4 4 4

Development X Spread Study:-ealth Surveys 5S 30X 22S 181 8X 8S 8S 1001

- 119 - Annex 7

REPUBLIC °F HUGAYMEATH SE S AD NANSEE PROJECT

Project Implementatlon Schedule

------ Distribution of Quantities------ TotalType Unit ----- ----- ----- ----- ----- ----- ----- Quantityof of Description YrI Yr2 Yr3 Yr4 Yr5 Yr6 Yr7 of

Component Input Input Fiscal 1993 1994 1995 1995 1997 1998 1999 Inputs

1.2 Ipstltutlonal Care

1.21 Stroke Proram

Consultant m/month STconsHL: equipmant specialist 1 0.5 0.5 2Equipment package Medical Equip:CT sceanners 6 6

Maintenance annual Equipment O&M 0 6 6 6 6 6Buildings Z Spread Refurbish 6 stroke facilities 1002 1002Consultant I Spread Bldg engineering/const superv 501 502 100lRecurrent unit Nonsal Oper Costs:CT scan supplies 0

1.22 Cardiovascular Diseases

Consultant m/month STcon:sBNequipment specialist 1 0.5 0.5 2Buildings X Spread Refurbish 5 cardiovase centers 1002 1001Consultant 2 Spread Bldg engineering/const superv SO5 502 100lEquipment package Med Equip:Bungar Inst Cardiology 1 1

Maintenance annual Equtipment 0ON 0 1 1 1 1 1Equipment package Med Equip:Sesumlweia Med School 1 1Maintenance annual Equipment O& 0 1 1 1 1 1Equipment package Med Equip.B.P.Posttrad Med Schl 1 1Maintenance annual Equipment 06M 0 1 I 1 1 1Equipment package Med Equip:Debrecen Medical School 1 1Maintenance annual Equipment 0&4 0 1 1 1 1 1Equipment package Med Equip:Sso.gd Medicel sce.,ol 1 1

Maintenance annual Equipment 0Cfi 0 1 1 1 1 1Equipment package Med Equip:Sseged Medical school 1 1

Maintenance annual Equipment O01 0 1 1 1 1 1Recurrent unit Nonsalary Operational Costa 1 1 1 1 1 5

Nonsalary Operational Costs1.23 Physical Rebabilitation

Consultant n/month STeons8L:equipment specialist 1 0.5 0.5 2Buildings X Spread Construction: SO5 501 100lMaintenance I Spread Building 0&M O0 SO5 100l 1OO2 1OOX 1002Consultant Z Spread Bldg design/ccnstrctn superv 202 502 302 1002Equipment package ICU equip:Natl Instit Med Rbhab 1 1

Maintenance annual Egquipment O0M 0 0 1 1 1 1Equipment package Med equip:Ratl Inatit Med Rebab 1 1

Maintenance annual Equipment O& 0 0 1 1 1 1Recurrent unilt Nonsal Oper Costs :DMR ICU 0.5 1 1 1 1 5Equipment package Ned *qy1p:CCunty locomot rebab depts 1 1

Maintenance annual Equipent O0M 0 0 1 1 1 1Equipment package Med equip:Balatonfured State oasp 1 1

Maintenanee annual Equipment O04 0 0 1 1 1 1Equipment package Med equip:other cardio rehab depts 1 1

Maintenance annual Equipment O&M 0 0 1 1 1 1Recurrent unit Hosp Rabab Ctrs:Msd censumab/supplies 1 1 1 1 1 5

- 120 - Annex 7

REPBIIC OF IRGhRYEAT HIRVICES AND ANALOMT EROJECT

Project Implementation Schedule

------ Distribution of Quantities- -- TotalType Unit ----- ----- ----- ----- ----- ----- ----- Quantity

of of Deacription Yrl Yr2 Yr3 Yr4 Yr5 Yr6 Yrt ofComponent input Input Fiscal 1993 1994 1995 1996 1997 1S98 1999 Inputa

2. OL1CY FA8IRS AL) F_EHBhT

2.1 Public Health anid Mnaaamnt ?ain1

2.11 Schgol of Health Services Management

Fellowship m/month ST Fell: 3 3 3 3 12Fellowship m/month LT Fell:8 PhD programs 24 72 96 72 24 280Development I Spread Curric/instretnal matla dev 102 302 80o 301 1002Consultant mn/month STconsHL:program evaluation 2 2 1 5Training X Spread ln-eoumtry training/pratitntrs 17 172I1 172 17X 17X 172 1002Computer package YC38U Hardware/Peripherals 2 28 30

Maintenance annual Computer C&H 2 2 30 30 30Computer package File Server: 1 GB storage 2 2Maintenance annual Computer O&M 0 0 2 2 2

Software package Database maeag _et software 1 14 15License annual Software license/upgrade 1 1 15 15 15 15

Software package LAN softwre 2 2License annual Software license/upgrade 0 0 2 2 2 2

Buildings 2 Spread Construction:Health Mgmt School 50X 502 1002Maintenance 2 Spread Building 0&M 0X 50X 1002 1002 1002 1002Consultant 2 Spread Bldg design/const supervision 202 502 302 1002Equipment package Training/AV equipment 1 1

Maintenance annual Equipment 004 0 0 1 1 1 1Equipment package Office Equipment 1 1

Maintenane annual Equipment 04 0 0 1 1 1 1Furniture 2 Spread School futniture 1002 1002Furniture package Computer desks 2 30 32Software package Books/Tecb journals 1 1Software annual Subscriptions 1 1 1 1 1 1 6Salary r/month Increm Salary:8 F/thee profess 48 S6 96 96 96 432Salary annual Increm Salary:Part time faculty 0.5 0.5 1 1 1 1 5salary m/month Increm Salary:1s residen superv 160 180 180 180 720Salary r/month Inorem Salary:Director 6 12 12 12 12 12 12 78Salary m/month Incren Salary: support/sec pool 24 48 84 84 84 84 408

Recurrent annual Nonsalary Operational Costs 0.5 0.5 1 1 1 1 5

- 121 - Annex 7

REPUILIC OF HUNGARYHUEAIS SERVICES AMN WANAAGEKT PROJECT

Project Implementation Schedule

-- Distribution of Quantites ------ TotalType unit -- ----- ----- ----- ----- ----- ----- Quantityof of Description Yrl Yr2 Yr3 Yr4 Yr5 Yr: Yr7 of

Component Input input Fiscal 1993 1994 1995 1996 1997 1998 1999 Inputs

2.12 School of Public Health

Fellowship rn/month ST Foll:atudy visits 4 8 10Fellowship r/onth LT Fell:25 NSc courses 36 120 so 6o 48 324Fellowship n/month LT Fell:PbD courses 24 48 48 24 144Fellowship n/month LT Fell:E15S fellowships 12 24 24 12 72Fellowship anmal LT FeUl:TNPUS supported N8c 5 5Consultant u/month L!consVL:direat FM 1 12 6 19Consultant /amonth STooaHL:sctool cur: planing 2 4 4 2 1 13Development X Spread Develop teaching modules 10l 301 401 20S 0OO1Buldings S Spread Returbish *chool faclities 1001 100l

Maintenance X Spread Building 0M01 OX 1OO 1001 lOOX 1001 lOO1Consultant X Spread Bldg englneering/const superv 401 601 1OOSFurniture X Spread School furniture 1OO1 1001Equipment package Training/AV/office equipment 1 1

Maintenance annual Equipment CUE 0 0 1 1 1 1Software package Library Books/software 1 1software annual Annual subscriptions 1 1 1 1 1 5Computer package PC386 Hardware/Peripberals 22 22

Maintenance annual Computer O&M 0 0 22 22 22 22Software package Database managment software 22 22License annual Software lioanse/upgrade 0 0 22 22 22 22Salary a/onth ncrem Salary:8 F/time faculty 24 48 96 96 96 96 456Salary m/month Inecr. Salary:Director 6 12 12 12 12 12 12 78Salary m/month lnre3 Salary: 4 adsdn staff 6 24 24 48 48 48 48 246

Recurrent annual Nonsalary Operational Costs 0.3 0.5 1 1 1 1 5

2.2 .2t art

2.21 )(3W CemutinrA Canter (Szckstard)

Consultant u/month STcomsBL:Applio sytem design 6 6Consultant r/month LTcnsHL:File conversion 12 12Consultant w/month STcendsL:Computer progrmer trg 8 6Fllowship r/month ST Fell:observation tour 2.5 3Computer package tMniacoputers (2) dual 2 2

Maintenance annual Computer 064 0 2 2 2 2 2Software package Database maemet software 1 1License SAnu S0ftwSre licese/upgrade 0 1 1 1 1 1

Software package Operating sytem/utilities soft 1 1Liense annual Software license/upgrade 0 1 1 1 1 1

- 122 - Annex Z

EPUBLIC OF HUNGARYHEALTH SERVICES AND NANAGMENT PROJECT

Project Implementation Schedule

------Distribution of Quantities------ TotalType Unit ----- ----- ----- ----- ----- ----- ----- Quantityof of Description Yri Yr2 Yr3 Yr4 Yr5 Yr6 Yr7 of

Component input Input Fiscal 1993 1994 1995 1996 1997 1998 1999 Inputs

2.22 Manaxement Information Sunoort Systems for HosnitalaPbase It Pilat NBEpitals (S)

Consultant nm/month STconsHL:Strategic syatems plan 2 2Consultant m/month STconaHL:Mnirmal data set 1 1Consultant n/month STcoensELiRaebursement 2 2Consultant nM/month STconsHL:M1S market survey 1 1Consultant r/month STconsHL:Data for external inst 2 2Consultant rn/month STccna8L:System design 6 6Consultant m/month STconsHL:FS selectu/modificatio 1 1Consultant u/month SToonsHL:Procurement/bid eval 1 1

Training Z Spread TA counterparts:applic devel 40S 60X 100lFellowship u/month ST Fell:overseas training 18 4 22 4 48

Training 2 Spread In-country training:users 36X 472 171 100lBuildings unit Refurbish pilot sites 5 5Computer paokage PC386 Bardware/Periph(25/hosp) 125 125

Maintenance annual Computer OWM 0 125 125 125 125 125Computer package PC28S Bardware/Periph(25/hosp) 125 125

Maintenance annuaL Computer O&M 0 125 125 125 125 125Computer paokage File servers/lOB storge(5/hosp) 25 25

Maintenance annual Computer O&M 0 25 25 25 25 25Computer package Optical disks (2/hosp) 10 10

Maintenance annual Computer OUM 0 10 10 10 10 10Computer package NEXT workstation (1/hosp) 5 5

Maintenance annual Computer OM 0 5 5 5 5 5Computer package Palmtop terminal (4/hosp) 20 20

Maintenance annual Computer OW 0 20 20 20 20 20Software package Database msment softwere(5/hosp) 25 25License annual Software license/upgrade 0 25 25 25 25 25

Software package LAN software(5/hosp) 25 25License annual Software license/upgrade 0 25 25 25 25 25

Materials unit LAN cables 1 1Equipment package Computer equipoent instaUlation 1002 1Furniture unit Computer furniture 300 300Equipment package Office Equipment 5 5

Maintenance annual Equipment OM 0 5 5 5 5 5Salary m/month Increm Salary: 10 tech staff 60 120 120 120 80 680License annual Comunic Software license/upgrade 1 1 1 1 1

Recurrent annual Nonsal Oper:comiunications charges 1 1 1 1 1 5

- 123 - Anex 7

REPUBLIC OF HUNGARYHEALTH SERVICES AID NAGNtEMT PROJECT

Project Implementation Schedule

------ Distribution of Quantities------ TotalType Unit ---- ----- ----- ----- ----- ----- ----- Quantityof of Description Yrl Yr2 Yr3 Yr4 YrS Yr6 Yr7 of

Component Input Input Fiscal 1993 1994 1995 1996 1997 1998 1999 Inputs

Pbase 2: Ebapital (20)Consultant n/month LSconaLL: Install supp/msnagmt 12 12 12 12 48Consultant m/month LTconaLL: Install supp/data conver 12 12 24Consultant m/month LTconaLL: InstaU supp/documentation 12 12Consultant m/month STconsLL Install supp/softwr customis 12 12 12 12 12 60Training X Spread In-country training:users 100X 100SComputer package PC386 Hardwaze/Periph(25/hosp) 500 500

Maintenance annual Computer O&H 0 0 S00 Soo 500 sooComputer package PC286 Hardware/Periph(25/hosp) 500 500

Maintenance annual Computer OH 0 0 500 500 500 500Computer package File servers/lOB storge(5/hosp) 100 100

Maintenance annual Computer O&M 0 0 100 100 100 100Computer package Optical disks (2/hosp) 50 50

Maintenance annual Computer 0&4 0 0 50 50 50 SoSoftware package Database maent software(5/hoap) 125 125License annual Software licene/upgrade 0 0 125 125 125 125

Software package LAN softwareC5/hosp) 125 125License annual Software license/upgrade 0 0 125 125 125 125

Equipment package Computer equSipment installation 1OOX 1Furniture unit Computer furniture 1100 1,100

Phase 3: Hospitals (135)Training X Spread In-country training:users 100l 100lComputer package PC386 Hardware/Periph(5/hosp) 675 675

Maintenance annual Computer O&M 0 0 0 675 675 675Computer package File servers/lOU storge(l/hosp) 135 135

Maintenance annual Computer O& 0 0 0 135 135 135Software package Database ugment software(1/hosp) 135 135License annual Softwore license/upgrade 0 0 0 135 135 135

Software package Finan Managmt applic software(l/hosp) 135 135License annual Software license/upgrade 0 0 0 135 135 135

Equipment packsge Computer equipment installation 1OOS 1Furniture unit Computer furniture 810 610Computer package PC386 Hardware/Perip(45 inat) 45 45

Maintenance annual Computer O& 0 45 45 45 45 45Software package Database management software 45 45License annual Software license/upgrade 0 45 45 45 45 45

Furniture unit Computer furniture 45 45

- 124 - Annex 7

REPUBLIC OF HUNGARYHEALTH SERVICES AND NANAGEMENT PROJECT

Project Implementation Schedule

------Distribution of Quantities------ TotalType Unit ----- ----- ----- ----- ----- ----- ----- Quantityof of Description Yrl Yr2 Yr3 Yr4 Yr5 Yr6 Yr7 of

Component Input Input Fiscal 1993 1994 1995 1996 1997 1998 1999 lnputs

2.3 Ekotect ranmeme_t Unit

2.31 Prosect Menaaement Unit

Consultant n/month LTconsHL:ProJeCt Management 16 36 36 12 3 3 3 111Fellowship m/month ST Fell:Observation tour 3 3 6Computer package PC386 Hardware/Peripherals 2 2

Maintemance annual Computer O&M 2 2 2 2 2 2Software package Database management Software 2 2License annual PC Software license/upgrade 2 2 2 2 2 2

Equipment package Office Equipment 1 1Maintenance annual Equipment O&M 1 1 1 1 1 1Recurrent annual Nonsalary Operational Costs 0.5 1 1 1 1 1 1 7

2.4 PtnesNat Studie

2.41 PregDr ion of Preirvestment Studies

Development X Spread Preinvestment Study 20S 501 301 1OOlDevelopment S Spread Feasibility study for quality control 201 401 401 1001

- 125 - Annex

REPUBLIC OF HUNGARY

HEALTH SERVICES AND MANAGEMENT PROJECT

Proigct Management and Implementation Arrangements

1. Overvie. The Project will be implemented over a seven-year period,and is expected to be completed by December 31, 1999. It will be implgmentedby the Ministry of Welfare (MOW), public health institutions, local governmenthealth services, medical universities and the Central Statistical Office(CSO). The coordination of all project-related activities will be theresponsibility of the Project Management Unit (PMU), within the Ministry ofWelfare. The Project implementation arrangements are as follows:

2. Project Management and Coordination. Overall responsibility forcoordination during implementation will rest with the PMU. The PMU willfacilitate resource flows to the implementing units, and channel major projectissues that may arise to the immediate attention of MOW management andexternal agencies including the Bank, for resolution. The PMU will not designor implement programs and activities supported by the Project, as this will bethe responsibility of existing MOW line departments and the institutionsdescribed below. The PMU is headed by a full-time Project Manager assisted bytwo full-time senior coordinators, and supported in its day to day operationsby technical staff (at least three positions) and support personnel (at leasttwo positions) with skills in accounting, contract monitoring, informationprocessing, and records management. Specifically, the PMU will:

(a) be responsible for ensuring that financial resources required underthe Project are made available to the implementing agencies in atimely manner. The PHU will monitor the movement of documents andcontracts through the bureaucratic approval processes and undertakemeasures to expedite their release;

(b) liaise with the Bank and other involved agencies for projectadministration and supervision purposes;

(c) monitor the availability of Government counterpart funds byconsolidating estimates of budgetary needs (investment and recurrent)of the Project (prepared by the implementing agencies) for theimmediately following financial year, sufficiently ahead of time inorder to obtain the comments and concurrence of the interestedagencies, including the Bank, prior to submission forGovernment/Parliamentary approval;

(d) monitor project expenditures and costs (local and foreign), processloan disbursement applications in collaboration with the NationalBank of Hungary and keep track of disbursements of the Bank loan andGovernment counterpart funds;

- 126 - Annex 8

(e) monitor compliance with the Bank Procurement Guidelines in theacquisition of equipment and software packages, administration ofsuppliers' and technical assistance contracts, as well as fellowshipand training plans for all MOW departments/institutions, includinghigher levels of management, involved in project implementation;

(f) monitor the placement and performance of staff receiving training inHungary and abroad, and of the consultants hired under the Project;

(g) prepare and distribute consolidated periodic reports to the relevantgovernment and other participating institutions, including the Bank,reflecting: (i) the status of implementation progress, problemsencountered and corrective actions needed; and (ii) current costs ofeach project component and estimated costs of completion;

(h) ensure the timely preparation and submission to relevant governmentinstitutions and the Bank of annual audit reports of projectexpenditure (including SOEs) and accounts; and

(i) be responsible for preparing the Project Completion Report (PCR) atthe end of project implementation.

3. Project ImDlementation Arrangements. The implementation of eachproject sub-component (Chart 3.1) will be the responsibility of theappropriate MOW department or other agency described below. The ProjectOperational Manual (POM) describes for each component: (a) project actionmatrices; (b) detailed terms of reference (TORs) for the necessary technicalassistance; (c) sample progress reporting and monitoring formats; and (d) atechnical background as appropriate. In view of limited implementationcapability in some areas of project intervention, the MOW will hire additionalprofessional staff to manage selected programs.

4. Each agency or unit identified should liaise with the PMU to ensurethe timely flow of resources for implementing its programs. Typically, eachimplementing agency will be responsible for the following activities:

(a) finalizing TORs for TA, fellowships and training requirements,preparation of short-lists, and technical evaluation of TA proposalsreceived;

(b) collaborating with the PMU, implementing agencies, and specialists inpreparing equipment lists, detailed specifications and procurementdocuments, reviewing bid packages and evaluating offers received;

(c) preparing detailed procedures and implementation schedules for itsprogram(s) and identifying and tapping local expertise needed toimplement these programs;

(d) defining physical targets and preparing estimates of financialresources needed to support future actions; and

- 127 - Annex 8

(e) collecting, collating and disseminating information and preparingreports about the progress of implementation of its activities.

5. The specific implementation responsibilities of each institutionalunit are as follows:

COMPONENT 1 - HEALTH SERVICES DEVELOPMENT.

(a) Pblig Health. Overall responsibility for this component will restwith the MOW Chief Medical Officer (CMO). The Public Health ProgramUnit fPHPU) attached to the Office of the CMO will coordinate/managethe operations in the five project sub-components of the publichealth program, and be responsible for the actions described in para4 (a)-(e) above. The PHPU will be staffed as follows: a Director(with public health and managerial experience), a Project Manager,two epidemiologists, two health policy specialists, an informationspecialist, a communication specialist, two data analysts, tworesearch assistants, and five secretaries. The PHPU wiil liaise withthe PMU to ensure the timely flow of adequate resources for thepublic health activities, and collaborate with other institutions,such as, with the Semmelweis Medical University in implementing theSchool of Public Health sub-component. The specific implementationresponsibilities for the sub-components of the public health programare as follows:

Mi) Strengthening of the NPHC and management of the Close the GanProgram will be the responsibility of PHPU. Specialists willbe contracted as needed to assist PHPU develop a strategicplan for the public health sector.

(ii) Chronic Disease Primary Prevention will be the responsibilityof the National Institute of Health Promotion (NIHP). Thecommunity intervention programs will be contracted to aHungarian University or NGO for implementation, under theoversight of the NIHP.

(iii) Chrgnic Diseases Secondary Prevention and implementation ofall the oncological activities in this sub-component will bethe responsibility of the National Institute of Oncology.

(iv) School Health will be the responsibility of the NIHP. Thetraining of teachers and primary doctors working in schoolsfor the improvement of school-based public healthinterventions, as well as the development of a national healthbehavior survey will be undertaken in collaboration with theNational Institute of Pediatrics.

(v) Hungarian Health Surveys will be the responsibility of theCentral Statistical Office (CSO). The surveys will becontracted out to a qualified research institute/agencyselected in accordance with the Bank's guidelines forconsulting services.

- 128 - Annex 8

(b) Institutional Care. Implementation of this sub-component will be theresponsibility of the MOW dependents in charge of health policy andmedical technology. With the assistance of specialists contractedunder the Project, the HPD will prepare detailed technicalspecifications of all equipment, bidding documents, conduct the pre-qualification (where needed) and tendering processes (from invitingbids through contract award) in accordance with Bank procurementguidelines, and oversee the delivery, installation and finalacceptance of equipment. The HPD will coordinate with the PMU tofacilitate resource/fund flows and communication with externalagencies such as the National Bank and the World Bank.

(i) Stroke Program. In implementing this sub-component, theHealth Policy Department (HPD) will collaborate with a taskforce of clinical and equipment experts from the StrokePrograms within HPD (a joint undertaking of the strokedepartments of the Neurological and Psychiatric Clinics of theSemmelweis Medical University), as well as the Directors ofthe six recipient hospitals (Uzsoki Street Hospital-Budapest;Kerepestarsca Hospital-Pest County; Esztergom Hospital-KomaronCounty; Salgotarjan Hospital-Nograd County; Szeged Hospital-Csongrad County; and Senmelweis Medical University-Budapest).

(ii) Cardiovascular Diseases. In implementing this sub-component,the HPD will collaborate with a task force of clinical andequipment experts from the National Institute of Cardiology(NIC), as well as the Directors of the five recipientinstitutes (HIC; Szeged Medical University; Semmelweis MedicalUniversity; Debrecen Medical University; B.P.Post-graduateMedical University).

(iii) physical Rehabilitation. In implementing this sub-component,the HPD will collaborate with a task force composed ofclinical and equipment experts from the National Institute ofMedical Rehabilitation (NIMR), the NIC, and representatives ofthe Balatonfured State Hospital and regional healthauthorities where the sub-component will be implemented.

COMPONENT 2 - POLICY-MAKING AND MANAGEMENT

(a) Public Health and Management Training. The CMO will have overallresponsibility for this sub-component. Implementation of the programand organization of the schools will be undertaken by the SemmelweisUniversity in collaboration with the PHPU, and in coordination withthe PMU for ensuring timely resource flows to the sub-component andliaison with external agencies including the Bank.

(i) School of Health Services Management sub-component will beimplemented by the Semmelweis Medical University.

- 129 - Annex-8

(ii) School of Public Health sub-component will be implemented bythe Semmelweis Medical University in collaboration with thePHPU and CMO.

(b) Management Support System. Overall responsibility for implementingthis sub-component will rest with the MOW Information Department.Procurement of all computer equipment and software will be undertakenby the HPD in collaboration with the Health Information Center(Hinfoc) and individual implementing hospitals with assistance fromspecialists contracted under the Project.

(i) MOW Computing Center. This sub-component will be implementedby the Hinfoc in collaboration with HPD.

(ii) Management Information Support System. This sub-componentwill be implemented by the Hinfoc in collaboration with theHPD and the management of the recipient hospitals. Initially,the information support system will be piloted in fivehospitals, and after satisfactory testing is completed,expanded to 20 additional hospitals. The rest of theHungarian hospitals will receive the final version of the twomain Feeder System (FS) modules only.

(c) Project Management Unit. The PMJ's day-to-day operations will besupported by full-time technical/support staff with skills inaccounting, contract monitoring, information processing, and recordsmanagement. Given the Project complexity and to supportinstitutional strengthening in the MOW, the Project will providetechnical assistance (110 staff months) to PMU and all units incharge of implementing the project, in the areas of projectmanagement, planning, procurement and contract administration.Intensive TA support is planned (about 36 staff months per year)during the first three years of implementation. This TA support isexpected to taper off during the latter half of the implementationperiod to about 1-3 staff months per year once the PMU and the HPDhave acquired sufficient expertise. At appraisal, the TORs as wellas the procedures for contracting the Project management assistanceto the PMU were reviewed by the mission and the MOW.

(d) Preinvestment Studies. Implementation of this sub-component will bethe responsibility of the Policy Development Unit of the Ministry ofWelfare.

Fiaure 9. 1: IMPLMENTING ANCIES OF THS HUNGARIAN M

mow~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-

dnistegr

Legal8NDcretary Health gementCn dgof Inform. Informatlon

Rtate Center Support iysten

I I 1 _ l,,~~I ISconlmc Policy |C 10 SocLalDepPrtmetnt Depament | Public Departt

Health llUnertled realtb

honancial da toary 4c leryManagemetnt Depatmn Ccar Tetchnical Health Carl k

_ _ Actl~~~-on Deparetnt ACV=Lo Action

-Budgett-Accountinq .. r,--Legal IAccount M D |Cardiovasc.|-Coordination |Butdgett N ursing |Program -Monitoring IDRGII I-Reporti ng III

|Publi>c R. Occupat. Me ldical ||:school s-- emaetlw. T herapy ||Rethab. |H ealth M. University |Allied |ProgramSchool 0 . Worker|

PLgue 9.2 ORg aN?OEL CHRT OP Tun HUNGARIAN Km

NATION AINISgRSOCIAL INS. OF WRLAI .(Independent) -I GOVEP_TSupervisd by CABINEST,MSSONgthe MLaLster I _ NT611A

. . _. . .Cablnet _Spolew - lc:0ZlS8S0WOfflos ~~~~~~~~~~~~~Sec. Crlsl

8poklan'Q llgmt. Offct ~~~~Office

I PolLtLcal permanenR n t PHealth Social NationalI State Beer. Statc seat. Research Policy Health

Board Board PromotionI sea 8 ct. s l 18tate seat.1 fe.1 -ect. nd

OtfLco~~~I

J | , X I d 0ff1¢ f- l 4 80ct. 8c. -,ffri

l _ l~~ ~ ~~l Helt Plic oLlPl

1~ ~~~Bertra Secretariat | |c|reta. |It

I~~~~ VI II TX .,.

Department Deptment I I Deputy t

II~~~~~ XIV g. ll

~I HEducatonse xx AuFltnanla v f He 1healthc li lr 8¢awL rPCLIcDepartment | e^tt|{1Departwnt: yot Policy;b n

IVa -- l -- l , XO |Vr| IV- -'

Legislation HudgtLng catastrophe ZvIepartment Diepartgnt | s n t PolLcy

I I IInternational H Ill xHIRelations 1oom$I Pharma¢eutL H Public PollcyDepartment Direotorate |OP"bat D rtment

XVIr ' V,-- -Informatlcal medial mm.Department epu nt

NationalInt of 8PA-S

- 133 - ANNEX 1Q

REPBLIC OF HUNGARY

HEALTH SERVIgES AN ANAGEMENT PROJECT

Supervision Pla

Timing Staff Wee Staffing

CY1993 30 weeks Bank resources (30 weeks) of which:- Task manager (12 weeks)- Implementation/Operations specialist

(10 weeks)- Information systems (3 weeks)- Other - not yet specified (5 weeks)

[Supplementary technical inputs will berequested through bilateral/multilateralcooperation in the following areas: publichealth specialist, health economics,health planner, management development,public health education and healthinformation systems specialist.]

CY1994 20 weeks Bank resources (20 weeks) of which:- Task manager (12 weeks)- Implementation/Operations specialist(8 weeks)

[Supplementary technical inputs will berequested through bilateral/multilateralcooperation in the following areas: publichealth specialist, health economics,health planner, management development,public health education and healthinformatiosu systems specialist.]

CY1995 20 weeks Bank resources (20 weeks) of which:- Task manager (12 weeks)- Implementation/Operations specialist(8 weeks)

[Supplementary technical inputs will berequested through bilateral/multilateralcooperation in the following areas: publichealth specialist, health economics,health planner, management development,public health education and healthinformation systems specialist.]

- 134 - ANNEX-10

CY1996 18 weeks Bank resources (18 weeks) of which:- Task manager (10 weeks)- Implementation/Operations specialist(8 weeks)

[Supplementary technical inputs will berequested through bilateral/multilateralcooperation in the following areas: publichealth specialist, health economics,health planner, management development,public health education and healthinformation systems specialist.]

CY1997 15 weeks Bank resources (15 weeks) of which:- Task manager (8 weeks)- Implementation/Operations specialist(7 weeks)

(Supplementary technical inputs will berequested through bilateral/multilateralcooperation in the following areas: publichealth specialist, health economics,health planner, management development,public health education and healthinformation systems specialist.]

cY1998 15 weeks Bank resources (15 weeks) of which:- Task manager (8 weeks)- Implementation/Operations specialist(7 weeks)

[Supplementary technical inputs will berequested through bilateral/multilateralcooperation in the following areas. publichealth specialist, health economics,health planner, management development,public health education and healthinformation systems specialist.]

CY1999 15 weeks Bank resources (15 weeks) of which:- Task manager (8 weeks)- Implementation/Operations specialist(7 weeks)

[Supplementary technical inputs will berequested through bilateral/multilateralcooperation in the following areas: publichealth specialist, health economics,health planner, management development,public health education and healthinformation systems specialist.]

- 135 - A = 1

REPUBIJC 01 HMWARYHEALTH SERVICES AMD NANAGEMN PROJCT

Technical Assistance Schedule

SUMMARY55 OF P R TI AL LSTAMUOR ITi if i i fr if if IT 1- TOTI. PackuaslI UUTWZ AM AREA OF 81PCIMJzAnI 1 66 1964 1Ms 186 1no 186 186 IauiII No.

-- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -F OLICT Ipregaration of studies: I Iaueto a--: I

I SUPEWT I?re-investumet, study j 201 501 501

I PODET ISuecislist Services for: I I II PBZPARATICEIPUBLIC HEATH1I I I AND IChronio Disease Primary Prevention I 13 12.5 12.5 12.5 12.5 12.5 8 3 I 2

DhIMLEM- IChronio Disease Secondary Prevention 6.5 18.5 18. 5 12.5 8.5 6.5 6.5 76 3 I TAUZOP ISchool Health 12 12 12 12 12 12 121 841 4

I ~~~IHungarian Heal.~h Surveys I 7 12 6 251 5

I I ~~INSTITUTIONAL CAREI I II ~~~IStroke Program I 1 0.5 0.5 2 6 II ~~~iCardiovasouLar Diseases I I1 0.5 0.5 I I~~~Physical Rehabilitation I 1 0.5 0.5 1 2 a I ~~~I II ~~~PUBLIC HEALTH & t4AR0DMU THAIN IE I II ~~~IScbool of Health Services Mansagemet I2 2 i sI S

1Scbool of Public Health 3 16 10 I 1 I 321 10o

IMANAGDMENT SUPPORT SYSTEMSI II ~~~IPOW Computing Center (Szeksuard) I 24 1 24 I11 I

iPhase 2: Hospital.s (20) 56 48 24 24 12 1441 12

I ~~~IPRJCT 1M U1853653612 3 3 3 I 13

I I~~~Prenaration of studies: I Cowleti&n .zs&a: I II ~~~Ifeasibility studly for quality controll 201 402 401 I

-- -- - -- -I-- - - - - - - - - -- - - - - - - - -I-- - - - - - - - - - - - - - - - - - - - -I-- -- -I--- --- II ISTIIU- Isrecialist Services for: I I I II TIOPAL IPUELIC HEALTH I I I I DVlLOftWInStrensthenina of the NPM 38 66 68O SS 5 5 SI 227114 I

lKwmIAamN SUPPORT SYSTU JMptL. Informn. Support for Hospitals j16 is6 1

Ipreparstion of st.udies: I I I

IPUDLIC HELTH CI ItinI tIIclosins the Gap Prosras 72 1.41 141 212 141 141 141 IChronic Disease Primary Prevention I I II Stuidy: Conunity Demonstration s 8 171 171 172 1,1 171 exI I Anti-waokinA yrogarm 1141 141 141 141 141 141 141 IIChronic Disease Secondary Prevention I 501 501olI School Health I141 141 142 14X 142 141 141 %Iflunsarian Health Surveys St 502 22 181 sI 81 811 I ISCHOOL OF HEALTH SERVCES MANAGEMENTII I IICurricUlun/instructioama material I11 0 202 3301 j IO 9 I

ISCImOFL0 PUBLIC HEATH s ID-1elp teaching~ modules I101 301 401 201 to 1I IIfeIlowethips/Loost Trainina for; I PUBLIC HEALTHI IStrangthening of thelNM is 1 30 30 1s 6 6 1141 14 IIChronic Disease Primary Prevention I a 2 1 1 a 2 IlChronic Disease Secondary Prevention 5.5 1 5 1 I 3 3 ISchoolHsealth I 5 3 2 2 2 21 lot 4jHungarian Health Sur7eys 1 0.5 2 I S

ISOHOO OF HEALTH SERVCErS HMANAEHT 27 75 98 75 24 3 00 I

IsciCO OF PUBLIC HALTH 4 85 192 122 06 46 I 55 to0

IKAN O MSUPPRMT SYSTEM I I IIW Computing Center (Ssekssard) I2.5 3 1 ItItIgat. inform. Support for Hsupitals I 16 4 22 4 I 481 15 II I I IIIROJETZ4AAGUTUNMT I 3 I I 1 IS…I…V. ……… I… I…~~~~~~~~~~~~~~~~- -------

- 136 - ANM5 112

REPUBLrC OPNNGla=H SERVICRS AND NANAOMWT PROJRCT

Technical Assistance Schedule

I CONSULTANT SERVICES (staff months) F n T nTY FTY nT FY | CEMPONENT/AREA OF SPECIALIZATION I 1903 1904 1095 1996 1907 l00e 1999 iTotal I

I1 Ue sm:s a I I II 1.1 PubIlic ll&lt I I I

1.1 Strenathenina of the NPHC I

I Lteonsbl: Institutional development | 6 12 12 6 35 || STconsEL lnstitutional development | 4 4 4 4 3 3 3 | 2S |I STconsML: Institutional development 4 4 4 4 2 2 2 | 22 |I STconsLL: Institutional development | 24 48 48 24 | 144 |

I 1.12 Chronic Disease Primary Prevention I

| STconsEL:coamunity intervention I 1 1 0.5 0.5 0.5 0.5 0.5 | 5LTconsBL cocmunity intervention I 6 12 12 12 12 12 12 I 78

1 1.13 Chronic Disease Secondary Prevention I I I

| STconsHL:mammography | 0.5 0.5 0.5 0.5 0.5 0.5 0.5 | 4 || STconsHL:nelyst/canoer registration | 6 12 12 6 3 S6 |

STconsML:evaluation 3 pro8ran 6 6 8 6 6 6 I 36

I 114 School ealth

I LTconsLL:Program manasger | 12 12 12 12 12 12 12 | 84 |

1.15 Hunnarian Health Surveys

I LTconsBL:health surveys | 6 12 6 1 24 |STconsL: survey planning I I

----------------------------------------------- I -1- ISubtotal: 70.5 123.5 117 75 36 36 36 494

-------------- ---- -I

1.2 Instltutild Cara n | I1.21 Stroke Proaran I

STconsHL:eqpipment specialist 1 0.5 0.5 | 21| Bldg engineering/construotion superv j 50S 50X tlump nm contract)

I 1.22 Cardiovascular Diseases I f| STeonsEL:equipment specialist I 1 0.5 0.5 | 2 |

| Bldg engineering/construction superv | 502 501 (lump san contract) I |

1.23 Physical Rehabilitation

STconsBL:equipment specialist I 1 0.5 0.5 | 2Bldg design/construction supervision 202 502 30X (lump sam contract) |

I Eobtotal: 3 1. 5 1.5 I 6j-------------------------------------------- ------------------------------------------ I

- 137 - ANNE 11

,RKPUBLIC OF RUNG=VIES AND NA&VQON PROJECT

Technical Assistance Schedule

i I-- I---I| CONSULTANT SERVICES (staf months) | FY FY PY TF FY FY FY | I| cCOPONtINVAREA OF SPECIALIZATION | 1993 1094 1995 1996 1997 198 18999 ITotaL I------------------------- I--------------------b--I- I

I ~~~ ~~~~~~~~~~I I 2. POLICY FAEIRBW Aon u |I

I ~~~ ~~~~~~~~~~I I 12.21 public Health and mt4naaemet Trainim I I|

I 2.11 Sehool of Bealtb Services Manaseent

STconsSL:program evaluation I 2 2 1 I 5I | Bldg design/construction supervision I 20X 5O0 30S (lump sum contract) I I

I ~~~~~~~~~~~~~III 2.12 School of Public Health I

I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~I | LTconsBL:direct FM I 1 12 6 I 19 I| STconsBL:school curriculum planning | 2 4 4 2 1 1 13 1

Bldg design/construction supervision | 40X 601 (lump sun contract) |-------------------------- I------------- - ----------

I 8Subtata I 3 16 10 4 3 1 1 37 1----------------------------------------------- ---------- - ------------------------------ _

2.2 Itla tIunIort Itt

I 2.21 MOW Computing Center (Sxeksazrd) I

| STMonsHL:Application sstems design | 6 | 6|| LeTonsBL:File conversion | 12 | 12 |

STconsHL:Computer progrmr training 6

2.22 Mnamement Info=mation Sunnort S,Ystms f-oL hossitals

I uPhse 1: Plt 0spita (5) I I I STconsIL:Strategic systms plan | 2 | 2|I STconsHL:Minimal data set I 1 I| STeonsEL:Reimbursement 2 2 |I 8TcensHL:I8 market survey I 1 I

STcensBL:Data for azternal lnstitutionsI 2 I 21| STconsIL:System design 6 | 6| STconsBL:FS selection/modification 1 | 1|| STconsBL:Ptocurement/bid evluation | 1 | 1|

I EPhas 2: Hospitals (20)I LSTcnsLL:Iastallations support/managmt 12 12 12 12 48

LTcenLL: Install supp/data conversion 12 12 I 24 |LTconsLL:Install supp/documentation | 12 |12|

I STconsLL:Install supp/software customizl 12 12 12 12 122 60|--------------------------- -------------------------- --

I Subtotal: 1 16 24 36 48 24 24 121 1841----------------------------------------------------

12.3 Project _I I Iit

2.31 ProAset Manasmm nt Unit I I I

LTeonsBL:ProJsct Managem8nt 18 38 35 12 3 3 3 ill----------------------------------------------------- i-

Su*ttal: s18 36 36 12 3 3 311111----------------------------------------------- ------------------------------------------ - I

| U 81SII | TOMhLiiEMMS: 111 201 201 139 66 63 521 8321----------------------------------------------- I---------------------------- - -------------

- 138 - ANN 11

REPUBLIC OF HUNGARYHEALTH SERVICES AND NMAGE T PROJECT

Technical Assistance Schedule

| PREPARATION OF STUDIES/PROGRAMS FY FTY FY FY Pn FY Y | II ~ COMPONES/VAREA OF SPECIALSZAION | 1993 1994 1995 1998 1997 1998 1999 | |----------------------------------------------- ---------------- ___-----------------------

I I (Completion rates) I II 1.1 Public Health | | |

1. 11 Strengthening of the EPIC I I I

| Closing the Gap Program | 7X 141 141 211 141 14X 14Z1

I 1.12 Chronic Disease Primary Prevention I

| Study:Ccmunity demonstration | 8S 17X 172 172 17X 17X ZIX| Anti-smoking program | 141 142 14X 142 141 142 14Z1 I

| 1.13 Chronic Disease Secondary Prevention | I |

| Health education messages s 5O0 50S o l

1.14 School Health I I I

I Competitive Health promo pros 1 141 14X 141 14Z 141 141 1421 I

I 1.15 Hungarian Health Surveys I

I Study:H.alth Surveys 52 302 222 182 82 81 el1 1

12. POLICY MAKZIN AID MASAGEHET I I

I 2.1 Public Health and Management Training I I

| 2.11 School of Bealth Services ManAgement I I I

I Curriculuu/instructLinal materials dwvel IO1 301 301 301 I

| 2.12 School of Public Health

I Develop tsaching modules ! 10 302 40X 20S I I

2.4 Preinveetment Studies I | |

I 2.41 Preparation of Preirnvostment Studles |

| Prelnvestment Study | 202 502 302 1| Feasibility study for quality control I 201 40X 402 | |----------------------------------------------- ------------------------------------------

- 139 - ANNE 11

REPUBLIC OF HUNGARYHEALTH SERVICES AM NANAGE)GNT PROJEC

Technical Assistance Schedule

--------- ---------------- --------------------- -- )PELLOWSHIC AL TRAIRIlG (staff/mos) I FY FY FY FY JY FY FY |

I CIT/POUUTAREZA OF SPECIALIZATION 1 1993 1994 1995 1996 1997 1998 1999 |Total I

ji. uax.rnsmxc. ---------------------__ _ _ _ _ _ _ __ _ _ _ _ _ _ __ _ _ _ _ _ _ _ I__ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ I I1.E1ER1 D

1.1 publl¢ 8ealth I I I

1.11 Stresthenina of the NPNC

| ST Fellow(2):Study tour | 6 6 6 6 6 6 6| 42|LT Fellov(6)5 c program | 12 24 24 12 1 72 1

| 1.12 Chronic Disease Primary Prevention I I I

I ST Fell:Commnity intervention pro-reuisl 2 2 2 1 1 I 8

1. 13 Chronic Disease Secondarr Prevention

I ST FeU:Mamography/hypertension/cytoloI 3.5 3 I 7 |I Training:cytology I 1 1 1 1 1 4 |

Training:mammography I 1 1 | 2 |

1.14 Schol Health

| ST Fell:health education | 2 2 2 1 1 1 11 10|| In-country train/teachers/MDa I 1 1 1 1 1 1 1 |

I 1.15 Himaarian Health Surveys I I

I ST Fell:Survey planning I 1 0.5 | 21--------------------------------------------------- I-I

&Subtotl: 1 1471----------------------------------------------- ------------------------------------------ _

12. }LIC t AjND MIA=

12.1 Public Health and Kanasunst tralu

I 2.11 School of Health Services Manexemnt I I I

I S Fell: 1 3 3 3 3 I 12| LT PeLl:8 PhD programs | 24 72 96 72 24 1 288In-country training/practitioners I 171 171 171 17X 171 1711 I

| 2.12 School of Public Health | | I

ST Fell:study visits | 4 6 | 10| LT Fll:25 MSc courses | 36 120 60 60 48 | 324

LT Fell:PbD courses | 24 48 48 24 | 144I LT Fell:EIS fellowships | 12 24 24 12 72

LT Fell:TE4PUS supported MSc courses |S I s----------------------------------------------- ---------------------------------------- -I--I

SubtA.l: 1 955 I----------------------------------------------- I-------------------------------------- - - - - I 1-

- 140 - ANNEX 11

REPUBLIC OF HUNGARYHEALTH SERVICES AMD ANAGEMENT PROJECT

Technical Assistance Schedule

|IIS/LOCAL TRAINING (staff/mos) F FY FY FTY PY FY FY || CfAPCOMM T/A}EA OF SPUCIaIZATION | 1993 1994 1995 1997 1998 1999 ITotal |

I 2.2 I I I&mH dt

2.21 MOW Comutina Center (Szekszard) I I I

| ST Fell:obaervation tour | 2.5 | 3I

I 2.22 Menaesment Information Sumwort Systems for oswitals |

I 1:P ()I I II Aba. 1: Pilot Hospitals CS)II I| Training TA counterparts:applic devel I 402 602| ST Fell:overseas training i 18 4 22 4 | 48I In-countrY trainiU3-u9ers | 36X 47t 17 I

Phase 2: Doppitals (20)I In-country training:users 1001S

I Than. 3: Hospitals (135) I I Ii In-country training:users o 1OO0 I I------------------------------------------ - - -------

I 8btotwa: 511

I 2 3 lD eet sm a idt U n }

1 2.31 ProAect Hanaxement Unit

ST PellCbservatn tour/project menagemtl 3 3 I 6 1----------------------------------------- - --------- I

I &Subtotal: I I el

I 1TAL 1i: 1 l 11.159 I

a/ TotaL excludes local training pro8rms.

- 141 - Annex 12

REPUBLIC OF HUNGARYHEALTH SERVICES AND MANAGEMNT PROJECT

Schedule of Disbursements Al(US$ million)

PercentageLoan Disbursement (US$ mln) Difference-------- ---------------- Sector Disbursement Project

Calendar Fiscal Cumulat Profile OverProject -------------- -------------- Cumula- as 2 of ------------------ Regional

Year Year Semester Year Semester Periodic tive Total Regional Bankwide Profile

1992 2nd 1993 lot 0.0 0.0 - - - -Yearl 1993 lot 2nd 4.0 kv 4.0 42 32 32 22 -

2nd 1994 lst 0.0 4.0 42 6X 6X -1X +Year2 1994 Ist 2nd 6.0 10.0 112 102 102 12 +

2nd 1995 let 7.3 17.3 19X 14X 142 5 +Year3 1995 Ist 2nd 10.0 27.3 302 222 162 8X +

2nd 1996 1st 14.4 41.7 462 302 26X 162 +Year4 1996 Ist 2nd 10.0 51.7 572 382 342 192 +

2nd 1997 lit 9.5 61.2 672 462 462 212 +YearS 1997 1st 2nd 7.3 68.5 752 582 542 172 +

2nd 1998 1st 5.0 73.5 812 662 622 152 +Year6 1998 1st 2nd 4.0 77.5 852 742 742 112 +

2nd 1999 lst 4.0 81.5 89S 822 822 72 +Year? 1999 lit 2nd 4.2 85.7 942 862 90X 42 +

2nd 2000 1st 4.0 89.7 982 942 942 22+year8 2000 1st 2nd 1.3 S) 91.0 1002 98X 1OO2

2nd 2001 lst 1002

Total 91.0------------------------------------------------------------------ __---------__----_-.------------

Source: IhRD Central Operations DepartmentNote :IV Project assumes a sit month disbursement lag.b/ Initial deposit into Special AccountI/ Closing Date: June 30, 2000

- 143 -

REPUBLIC OF HUNGARY

HEALTH SERVICES AND MANAGEMENT PROJECT

GLOSSARY OF TERMS

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

Average Length of Stay - Number of hospital days/ number of admissions

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

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

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

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

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

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

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

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

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

- 145 -

REPUBLIC OF HUNGARY

HEALTH SERVICES AND MANAGEMENT PROJECT

BIBLIOGRAPHY OF MATERIALS IN THE PROJECT EILE

Comissioned Papers

Bleich, Howard L., Jerome Jackson and Edna Moody, "Information Support SystemsSubcomponent," April 1992

Centers for Disease Control (Atlanta, USA) and London School of Hygiene andTropical Medicine, "Public Health Subcomponent," July 1992 (Jeffrey Koplan,Richard Feachem, Tim Byers, Stephen Blount, Ward Cates, Klim McPherson,Michael Marmot, Peter Goldblatt, George Rubin Erkki Vartiainen, Martin McKeeand Charles Normand).

Centers for Disease Control (Atlanta, USA) and London School of Hygiene andTropical Medicine, "School of Public Health Subcomponent," July 1992 (MartinMcKee, Charles Normand, Jeffrey Koplan, Richard Feachem, Tim Byers, StephenBlount, Ward Cates, Klim McPherson, Michael Marmot, Peter Goldblatt, GeorgeRubin and Erkki Vartiainen, Martin McKee and Charles Normand).

Danish Health Group, "Institutional Care Subcomponent," July 1992 (BjarneRasmussen, Ole Nielsen, Astrid de Debuchy and John Roberts).

Danish National Board of Health, "Primary Health Care DevelopmentSubcomponent," July 1992 (Gunnar Schioeler, Niels Bentzen, Jan van Es, IngeNielsen, N. van Lin, Ulla Runge and Frank Ebson).

Deeble, John, "Health Insurance and the Structure of Health Services," May1992.

Dussault, Gilles, Richard Southby and George Johnson, "Review of HealthServices Management Education in Hungary," July 1992.

Dussault, Gilles, Richard Southby and George Johnson, "School of Public HealthSubcomponent,' July 1992.

Healthcare Enterprise International Inc., "Private Sector DevelopmentSubcomponent," July 1992 (Richard Eskow).

Kalina, Mathias, "Prehospital Emergency Services," July 1992.

Saltman, Deborah, "The Health Workforce in Hungary," May 1992.

Reports and Working Papers

Nicholas Barr, "The Hungarian Cash Benefit System," IBRD, EC1/2HR, 1992.

- 146 -

Refergnce

American International Health Care (1989), Reform within the Health Sector ofHune , Report to the Reform Task Force, June 1989.

Deeble J S, (1991), Medical Services through Medicare, Department of Health,Housing and Community Services, Australia, National Health Survey, BackgroundPaper No. 2.

Forgics I, (1988) "Hungary" in The International Handbook of Health CareSvstems, Saltman RB (Ed), Greenwood Press, New York.

International Monetary Fund (1990), Social Security Reform in Hungary, FiscalAffairs Department, October 1990.

Ministry of Welfare, Hungary (1991), Yearbook 1990, Budapest 1991.

OECD (1991), "Health Data File," 1990-91, Paris.

Sandier S, (1989), "Health Service Utilisation and Physician Income Trends",Health Care Financing Review, 1989 Supplement, pp 21-32.

Schieber G J, Poullier J-P and Greenwald L M, (1991), "Health Care Systems inTwenty-four Countries", Health Affairs, Fall 1991, pp 22-38.

World Bank (1990), Hunary: Health Services: Issues and Options for Reform,Working Paper, September 1990.

World Bank (1991a), Hungary: Reform and Decentralisation of the Public Sector,Draft report No. 100661-HUN, November 1991.

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