Argentina - Provincial Health Sector Development Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. P-6607-AR MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT TO THE EXECUTIVE DIRECTORS ON A PROPOSED LOAN IN AN AMOUNT EQUIVALENT TO US$101.4 MILLION TO TIE ARGENTINE REPUBLIC FOR A PROVINCIAL HEALTH SECTOR DEVELOPMENT PROJECT JULY 5, 1995 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS Current Unit = Argentine Peso (Arg$) US$1 = Arg$1 (March 1, 1995) FISCAL YEAR January 1 - December 31 GLOSSARY OF ABBREVIATIONS AND ACRONYMS ANSSAL Administraci6n Nacional de Seguros de Salud (National Administration of Health Insurance) BN Banco de la Naci6n Argentina (Bank of the Argentine Nation) CES Convenio de Ejecuci6n y Subsidiario del Prestamo Naci6n- Jurisdicci6n Conurbano Peri-urban area GBA Gran Buenos Aires (Greater Buenos Aires) HPA Hospital Piblico Autogestionado (Autonomous Public Hospital) ICB International Competitive Bidding ICR Implementation Completion Report LIB Limited International Bidding MCBA Municipalidad de Buenos Aires (Municipality of Buenos Aires) MIS Management Information System MOE Ministerio de Economia y Obras y Servicios Puiblicos (Ministry of Economy and Public Works) MSAS MIinisterio de Salud y Acci6n Social (Ministry of Health and Social Action) MSP Ministerio de Salud Provincial (Provincial Ministry of Health and MCBA) NCB National Competitive Bidding O&M Organizational and Management OSs Obras Sociales (Health Insurance Fund) PAMI Plan de Atenci6n Medica Integral PBA Province of Buenos Aires PIP Project Implementation Plan POM Province of Mendoza PRESSAL Proyecto de Reforma del Sector Salud (Provincial Health Sector Development Project) SOE Statement of Expenditures TOR Terms of Reference UEC Unidad Ejecutiva Central del Proyecto de Desarrollo del Sector Salud en las Provincias UEP Unidad Ejecutora Provincial UNDP United Nations Development Program  FOR OFFICIAL USE ONLY ARGENTINA PROVINCIAL HEALTH SECTOR DEVELOPMENT PROJECT Loan and Project Summary Borrower: Argentine Republic Implementing Agency: Ministry of Health and Social Action (MSAS), the Provinces of Buenos Aires (PBA) and Mendoza (POM), and the Municipality of Buenos Aires (MCBA) Poverty: Program of Targeted Interventions. Amount: US$101.4 million equivalent (including up to US$2.0 million equivalent of retroactive financing). Terrns: Standard variable interest rate, with maturity of 15 years, including five years of grace. Commitment Fee: 0.75% on undisbursed loan balances, beginning 60 days after signing, less any waiver. Financing Plan: See Schedule A Net Present Value Not applicable Staff Appraisal Report: No. 14399-AR Map: IBRD No. 25587 Project Identification Number: AR-PA-6030 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. |   MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE IBRD ON A PROPOSED LOAN TO THE ARGENTINE REPUBLIC FOR A PROVINCIAL HEALTH SECTOR DEVELOPMENT PROJECT 1. I submit for your approval the following memorandum and recommendation on a proposed loan to the Argentine Republic for the equivalent of US$101.4 million to help finance a project aimed at rationalizing health sector spending and improving the efficiency of health care delivery through transforming hospitals into autonomous entities in the public sector. The proposed loan would be at the Bank's standard interest rate, with a maturity of 15 years, including five years of grace. 2. Background. In 1989, Argentina embarked on an ambitious structural reform program to reverse a long period of economic stagnation. The program, which has been remarkable both in its scope and its implementation speed, has improved tax structure and administration, privatized public enterprises, reformed public administration, and reduced public employment. These measures, together with trade liberalization and a fixed exchange rate, have created a solid base for development. Sustaining growth and extending its benefits, however, will require consolidation of macroeconomics reforms and greater emphasis on human resource development. Since reform in the social sectors has lagged behind economic adjustment, the poor have suffered disproportionately from the country's past disarray. Health indicators are less satisfactory than the spending levels would predict. With per capita outlays for health services above US$400 ( i.e., health spending is rapidly approaching 10 percent of GDP), expenditures are well above those of middle- income countries such as Chile (US$250) and Costa Rica (US$160). Yet, both these countries have infant mortality rates--16 and 14 per 1,000 live births, respectively-lower than Argentina's 25 per 1,000. Furthermore, a prolonged period of declining fertility and increased life expectancy has resulted in an aging population, associated with a higher prevalence of chronic and degenerative diseases, such as vascular diseases, cancer, and traumas, which already account for 63 percent of all deaths. The transitional epidemiological profile (i.e., high incidence of infectious diseases and increased prevalence of chronic diseases) magnifies the level and complexity of future demands on the system. 3. The structure of the health finance and delivery systems reflects the complexity of the federal structure and the historic presence of unions in the management of welfare programs. The three sub-sectors- -public, quasi-public health insurance funds and private-constitute an intricate structure. The public sector accounts for about one-third of sector financing and 60 percent of the sector's installed capacity, and covers the uninsured and under-insured (i.e., 32 percent of the total population). Over the past decade, most public facilities have been decentralized to the provinces and municipalities. The federal Ministry of Health and Social Action (MSAS) remains, in theory, the policy-making, normative and regulatory authority. However, there is no clear-cut division of authority between the MSAS, provincial health ministries (MSPs) and municipal authorities. This results in complicated administrative and budget structures and weak policy- making. Furthermore, most public hospitals are old and inadequately maintained, have obsolete equipment, and are poorly managed. Internal inefficiencies are amplified by the lack of decision-making capacity and poor accountability of hospital directors. The occupational health insurance funds (Obras Sociales-OSs) account for 60 percent of sector financing and provide services to over half the population, mostly under contract with the private sector. There are over 300 OSs, and they vary widely in size, financial stability and benefits provided. Membership is compulsory for most workers, who are automatically assigned to a fund. OSs are funded by a 10.5 percent wage tax. Financing also involves federal budget transfers, provincial contributions and hidden subsidies through "free" assistance in public hospitals. Since individuals involved with OSs are required to contribute substantial co-payments, poorer beneficiaries increasingly resort to public  sector institutions. It is estimated that one-third of public hospital discharges involve OS beneficiaries, and that fees from OSs are collected in less than 20 percent of eligible cases. The private sector consists of financial intermediaries and providers. The sector, which accounts for over 40 percent of hospital admissions and a third of outpatient visits, has expanded rapidly in recent years as a result of skillfi4 marketing, growth of OSs, and consumer dissatisfaction with a decaying public sector. Most private sector services are provided under contracts with OSs and private insurance plans, which cover about three million people. 4. The health sector's long-term viability is threatened by a combination of factors that are principally associated with: (a) demographic dynamics--as the prevalence of chronic diseases increases, hospitals will experience a growing demand for high-cost services; (b) inefficient allocation of public funds, resulting primarily from (i) weak accountability of the provinces in the use of federal transfers, (ii) the intricate structure of the sector with its multiple stakeholders and a flawed health insurance system; (iii) the link between the financing and service deSivery roles of the public sector; and (c) serious production inefficiencies of public hospitals related to poor management and deteriorated facilities. Without action on reform in the areas of policy, regulation, and public hospitals, the sector's medium-term outlook is one of escalating costs and equity erosion. 5. In the past two years, legislation has been drafted and/or passed to reform two critical areas of the sector. First, Executive Decree 578 of 1993 establishes the basis for the reform of public hospitals and the legal foundation for their transformation into independent trusts. As of March 1995, 18 provinces and the MCBA (Municipality of Buenos Aires) had officially endorsed the decree. Second, a law was proposed in 1992 for an in-depth reform of the OS system that would have opened affiliation and improved regulation. The proposal was defeated in Congress, following strong opposition from the unions. Executive Decree 9 of 1993 restored a limited number of the initiatives and introduced competition by allowing consumer choice. In reference to the reform of public hospitals, the Government's aim is to initiate activities in the Greater Buenos Aires Metropolitan Area (GBA) and the Province of Mendoza (POM). The GBA has a population of about 11 million, about one-third of Argentina's population. It consists of the Municipality of Buenos Aires (MCBA), with 3 million inhabitants and the peri-urban area (Conurbano), divided into 19 counties belonging to the Province of Buenos Aires (PBA), with a population of 8 million. The public sector owns and manages about 50 percent of the hospital beds in the Metropolitan area. Hospital capacity is more concentrated in the city, where national referral specialized hospitals are located. However, only 40 percent of the citys hospital discharges are MCBA residents. The Province of Mendoza (POM) has a population of 1.4 million and slightly better health indicators than the national average. In the past five years, the POM has been a pioneer in the design and implementation of reforms in the health sector. 6. Government Strategy. The Government has linked the success of the adjustment program to the rationalization of social spending. In the health sector, a number of initiatives have been introduced to increase equity and efficiency. First, the Government has taken some steps, albeit limited, to reform the health insurance system. Second, the decentralization of services to provinces and municipalities has been practically completed. Third, new regulations have opened the way for competition in the pharmaceutical market. Fourth, the Government, with Bank's support, is commnitted to maternal and child health improvement. Fifth, as mentioned earlier, Executive Decree 578/93 of 1993 establishes the basis for the reform of public hospitals. The Government's commitment to reform in the health sector is hindered, however, by the complexity and heterogeneity of the sector and its problems, the overall lack of strong technical leadership, and the resistance to change from politically powerful groups. However, strong commitment to change and technical capacity can be identified at the level of individuals in the MSAS, provincial ministries, and hospitals. Appropriately, the Government has embraced a strategic approach to  health sector reform that is gradual, participatory, and based on the implementation of pilot and demonstration experiences. The Government has prepared a Letter of Sectoral Policy stating the main elements of its reform proposals, including the establishment of autonomous public hospitals (HFPAs). Although the legal basis for HPAs has been established, its actual implementation depends on updating the managerial model and systems of public hospitals in Argentina. Lack of full implementation of the HPA model since Executive Decree 578/93 of 1993 was passed has demonstrated that setting the appropriate legal environment is a necessary condition but it is far from being a sufficient one. 7. Rationale for Bank Involvement. The Bank's country assistance strategy (CAS), discussed by the Board on May 4, 1995, strongly supports the Government's ambitious reform program and focuses on: (a) consolidating reforms; (b) reducing poverty and supporting human resource development; and (c) rebuilding the deteriorated infrastructure base. In the social sectors, the Bank's assistance to support targeted efforts on poverty is complemented by broader efforts to improve the quality of human resource investments. As a first stage of Bank assistance in poverty alleviation, the ongoing Matermal and Child Health and Nutrifion Project (Ln. 3643-AR) is targeting poor mothers and young children in the urban poverty belts and the underdeveloped northern provinces. A follow-up operation would provide similar support to other provinces. The Bank is also preparing a Social Protection Project to assist in the design and coordination of efforts in poverty alleviation. To complement these efforts and to achieve improvements in the quality of investments, the proposed project and related Health Sector Financing Study and Health Insurance Reform Project under preparation would support the reform of the inefficiently run social health insurance system (OSs), in order to provide minimum health benefits to its members. While the proposed project would address reform through gradual and attainable changes in the delivery and contracting of services and in the regulation of private health insurance, the Health Sector Financing Study and proposed Health Insurance Reform Project would set the stage for politically sensitive reforms of the Obras Sociales system. The proposed project underpins a Government priority, complements the objectives of other Bank- financed projects and sector work, and as such is fully consistent with the Bank's country assistance strategy (CAS) for Argentina. 8. Project Objectives. The proposed project addresses the Government's sectoral policy goal of rationalizing sector spending by strengthening policy-making and improving efficiency in service delivery. To this end, the proposed project takes a two-pronged approach that integrates the Government's gradual strategic approach with sector reform. First, it would strengthen policy-making capacity of the MSAS and the MSPs (see also para. 3) and assist them in the actual implementation of specific changes to the incentive environment in which public hospitals operate. Second, it would improve the capacity of the MSPs to deliver health services by pilot-testing actual implementation of the HPAs through different alternatives of managerial models for the transformation of public hospitals into HPAs. To achieve these goals, the proposed project would carry out: (a) a limited number of operationally-oriented studies and systems to improve the incentive environment in which public hospitals operate; (b) the pilot implementation of HPAs in the MCBA and in the provinces of Buenos Aires and Mendoza; and (c) the nationwide dissemination of reform initiatives emerging from (a) and (b). 9. Based on the Government strategy presented to the Bank in the Policy Letter, the findings and recommendations of the studies (Component 1) and the experience gained in the implementation of the first phase of institutional strengthening in eligible hospitals (Component II), the Government would prepare an Action Plan to be presented to the Bank during the Mid-Term Review and to be implemented during the second half of project implementation. That plan would include, at a minimum, the actual (legal and in practice) transformation of at least one eligible hospital in each eligible province into an HPA and actions to  -4 - be taken to implement the recommendations of each of the studies under component I. Satisfactory progress in the implementation of the action plan would be a condition of disbursement for investments, other than the Management Information System (MIS), for the second phase of the last three hospitals in the respective eligible jurisdictions. 10. Project Description. The proposed project would consist of the following three components and related activities: Component I: Formulation of Policy Reform (6 percent of total project costs) would help establish the basis and provide critical tools to advance sector reform. The studies are designed to help fulflll the following objectives: (a) improve the sector's allocative efficiency; (b) improve the targeting of public subsidies; and (c) compensate for market failures in health insurance and service delivery. They would involve: (i) upgrading the national information system on sector resources, epidemiological information and the productivity of service delivery; (ii) defining priority services to be financed by government subsidies; (iii) designing a strategy to separate the financing and service delivery functions for the public sector; (iv) designing and pilot testing a public hospital reimbursement system at the provincial level; (v) designing a strategy to reform provincial OSs; (vi) designing a system to identify beneficiaries under various insurance schemes; and (vii) designing and implementing a regulatory framework for private health insurance and private health care providers. An additional set of studies would focus on developing investment and project proposals (e.g., expansion of the HPA initiative nationwide, reform of health insurance, AIDS control, and Mid- Term and project-impact evaluation studies) for which Bank funding is likely to be requested in the short- or medium-term. Finally, a study would analyze the relevant legislation and institutional framework for hospital waste management. Under this component, the proposed project would finance consulting services and training and workshops. Component II: Pilot Imnplementation of Independent Trust Hospitals (89 percent of total project costs) would help transform the organization and management of 15 hospitals (out of 300 nationwide) in three jurisdictions (Municipality of Buenos Aires--MCBA, Province of Buenos Aires-- PBA and Province of Mendoza--POM) to improve internal efficiency and guide their transformation into HPAs. The estimated number of eligible hospitals to be included in the project responds to: (i) the preliminary identification of those hospitals that would be eligible under the defined eligibility criteria; (ii) the minimum number that is considered to be effective in attaining the desired demonstration effect in Argentina; and (iii) the minimum number considered to test alternative organizational models before deciding which of them could be replicated nationwide. To this end, the project would support the following activities in the eligible hospitals: (a) institutional development with a focus on organization and management and hospital waste disposal; (b) implementing a hospital management information system (MIS); and (c) removing major bottlenecks for efficiency improvement through physical plant and equipment investments, conditioned upon measurable improvements in organization and management (with a ceiling per hospital of US$4.2 million for civil works and US$2.1 mnillion for equipment). Under this component, the proposed project would finance civil works and medical equipment, computer hardware and software applications, and consulting services. Component mI: Dissemination of Reform Initiatives (5 percent of total project costs) would help disseminate the findings and experiences of the first two components nationwide and strengthen the technical and management capacity of sector professionals. To this end, the project would  support: (a) training and workshops to increase the awareness and knowledge of sector reform nationwide, disseminate the findings of the studies of Component L and transfer the experience and knowledge drawn from the implementation of Component II; and (b) a limited number of international scholarships in the areas of hospital management, public health, and health economics. Funding for dissemination would be primarily directed to staff of provincial ministries and hospitals. An agreement (assistance agreement) would be signed between the MSAS and the entity requesting support. Under this component, the proposed project would finance training and workshops and consulting services. 11. Project Cost and Financing. The proposed project would be carried out over five years. The total project cost is estimated at US$144.7 million equivalent, including taxes (US$23.7 million equivalent). The foreign exchange component is estimated at US$82.21 million, or about 57 percent of total project cost. The proposed loan of US$101.4 million would finance 70 percent of total project cost. It would cover US$70.9 million or 98 percent of foreign exchange expenditures, and US$30.1 million or 63 percent of estimated local expenditures. The Government would finance US$43.3 million equivalent, or 30 percent of total project cost. 12. Project preparation has been financed with an advance from the Project Preparation Facility (PPF) of US$1,150,000 dated June 22, 1994, and amended on May 19, 1995. To facilitate timely project implementation the Government would establish, maintain and operate, under terms and conditions satisfactory to the Bank, a Special Account denominated in US Dollars with an authorized allocation of US$4.0 million attheBanco de laNaci6n. An initial deposit of US$1.0 millionwould be made and thefull arnount of the authorized allocation would be released when disbursements reach a level of US$10 million. Up to US$2.0 million (about 2 percent of total Bank financing) will be made available in retroactive financing for expenditures incurred up to 12 months prior to loan signing. 13. Project hnplementation. The MSAS would be responsible for project implementation. An MSAS resolution of September 1994 created the project preparation unit, i.e., Unidad de Coordinaci6n del Proyecto de Reforma del Sector Salud. Project execution responsibilities would be vested in a national project implementation unit, i.e., UnidadEjecutiva Central (UEC), consisting of about 16 higher-level staff. In addition, PBA, MCBA and POM would create jurisdictional implementation units, i.e., Unidades EjecutorasProvinciales (UEPs), consisting of about four higher-level staff, to assist in the implementation of Component II. The UEC's mandate would include: (a) carrying out Components I and Im; (b) providing technical and administrative support to the UEPs in carrying out Component II; (c) coordinating with and overseeing all relevant entities involved in project implementation at the national and jurisdictional levels; (d) monitoring and evaluation; and (e) reporting to the Bank. The UEPs' mandate focuses on the upgrading of physical plant under Component IL with the administrative and technical support of the UEC. Considering the critical nature of strong leadership in the implementation of reform in each eligible hospital, it will be a condition of disbursement for each eligible hospital that the respective hospital director has experience and qualifications acceptable to the MSAS through the PIU. 14. The proceeds of the loan allocated for upgrading of physical plant and equipment under Component II would be on-lent from the national Government (Ministerio de Economiay Obrasy Servicios Pzublicos de laNaci6n-MOE) to the three participating jurisdictions (i.e., PBA, MCBA, and POM). Thesejurisdictions would repay the proceeds of the loan to the MOE under the same terms and conditions as the Bank Loan. To this effect, a subsidiary loan agreement would be signed between the national MOE, the MSAS and each eligible jurisdiction. The eligible jurisdictions have signed a Commitment Letter with the MSAS expressing  - 6 - their willingness to participate in the project. Under Component II, other provinces could be eligible for financing to replace any of the three eligible jurisdictions already identified, in case of violation of the subsidiary loan agreement. The preparation unit has prepared an Implementation Manual to guide and monitor implementation. The Government and the Bank have agreed on a critical set of actions and monitoring indicators (Project Implementation Plan--PIP). During implementation, the Government and the Bank would hold Annual and Mid-Term Reviews to assess, inter alia, overall implementation progress, compliance with legal covenants, and the adequacy of available and programmed financing. Annual audits would be carried out by independent auditors acceptable to the Bank. The project's closing date would be June 30, 2001. 15. Project Sustainability. The proposed project would entail minimal incremental recurrent costs. Administrative costs related to the management of UEC and UEPs (e.g., secretarial support, rent and utilities, maintenance of office equipment and office supplies) represent less than 5 percent of total project cost and will be funded by the Government. Personnel cost is not recurrent, since the UEC and UEPs consist of consultants under short-term or medium-term contracts and these units are expected to be dismantled at the end of implementation. Project sustainability, however, is heavily dependent on the political will and the technical ability to incorporate the findings and recommendations of the studies (Component 1) and the lessons learned from the pilot experiences (Component II) into broader sector reform efforts. 16. Bank Experience and Lessons Learned. The project design builds on relevant operations financed by the Bank Group over the past decade. Successful implementation is closely associated with: linldng the definition of project objectives and scope to a clear policy framework; obtaining strong and pervasive government commitment; designing simple projects with focused and modest objectives; and linking the financing of critical investments to the implementation of policy and/or institutional reform. However, in particular in middle-income countries, special attention should be paid to ensure that simplicity is consistent with the need to address the most relevant sector issues, which are usually exceedingly complex in the area of health sector reform. These lessons have been incorporated into the project. 17. Key Issues and Actions. Prior to negotiations, (a) the Government prepared: (i) a Letter of Sectoral Policy stating its Health Sector Strategy and the main elements of its reform proposals and (ii) a final version of the Implementation Manual; (b) Commitment Letters were signed between the MSAS and each of the three jurisdictions participating in Component It; (c) the Government informed the Bank about its intention to continue with the cost-sharing agreement with UNDP (signed in June 1995, in the context of the PPF) to manage the contracting of consultant services; and (d) the Ministry of Economy (MOE) submitted a proposal for ensuring the timely availability of counterpart funds during implementation. 18. During negotiations, assurances were obtained from Government that: (a) an action plan, for the MSAS and for each eligible province, would be prepared no later than December 31, 1998 and the implementation of such plan finalized no later than nine months before the completion date; (b) the maximum amount allocated to civil works and equipment will not exceed US$6.3 million per hospital and the first phase of investments will not exceed 40% of the investment assigned to the respective hospital; (c) the annual amounts of counterpart funding would be made available for each of the five years of project implementation; (d) failure of performance by any of the three participating jurisdictions under their respective subsidiary loan agreement would be sufficient cause for suspension of disbursements in any of such jurisdictions, and other provinces could then be included; (e) no later than the Mid-Term Review of the project, the Government would present to the Bank a plan to transfer UEC and UEP responsibilities and activities to MSAS and respective jurisdictions; (f) the Government would carry out the project in accordance with the  Implementation Manual and within the parameters of the Project Implementation Plan; (g) a plan would be developed as an altemative to the UNDP-MSAS cost-sharing agreement for the second half of project implementation; (h) the Government, through the UEC, would submit to the Bank quarterly progress reports no later than 30 days after the end of every quarter of each year, and the last quarterly report of each calendar year would include an assessment of overall implementation progress over the past year; (i) a draft budget proposal for the folUowing year would be submitted to the Bank no later than June 30 of each year and an officially approved budget for the following year no later than 30 days after its approval by the Congress; and (j) annual reviews should take place no later than July 31 each year, and a Mid-Term Review should take place no later than July 31, 1998. During negotiations, the Bank and the Government agreed on the Project Implementation Plan. 19. Conditions of loan effectiveness would be that: (a) the MSAS-UNDP agreement (para. 17) has been amended to allow for the UNDP to support the MSAS in the management of all contracts for consultant services to be financed by the project; (b) the UEC has been created and is adequately staffed, and the coordinator has been appointed; (c) the Implementation Manual has been approved by the MSAS; and (d) all actions satisfactory to the Bank have been taken by the Government in order to permit procurement of goods and services financed by the Bank Loan in accordance with Bank procedures. Conditions of disbursement would be that: (a) for expenditures for civil works and equipment under Component II for the first two hospitals in each eligible jurisdiction, for the first phase (up to 400/o of the investments assigned to the respective hospital), the completion of a satisfactory investment plan; and for the remaining balance, reasonable progress in the implementation of institutional development activities; (b) in addition to (a) above, for expenditures on civil works and equipment for the second phase of investments under Component II for the last three hospitals in each eligible jurisdiction, the submission to the Bank of the action plan referred to in para. 9 and satisfactory advance in its implementation during the second half of project implementation.; (c) for each eligible jurisdiction under Component II, the subsidiary loan agreement would have been signed between the Federal Government, represented by the MOE and the MSAS, and the respective jurisdiction; (d) for expenditures for information systems, the submission of a master policy framework, acceptable to the Bank, to guide all MIS investments; (e) for expenditures for each of the three participating jurisdictions under Component II, the UEP has been created and is adequately staffed and the coordinator has been appointed; (f) for expenditures for each of the three participating jurisdictions under Component II, the corresponding parts of the Implementation Manual has been approved by the respective jurisdictions; and (g) for expenditures for each eligible hospital under Component II, the respective hospital has a director with experience and technical and managerial qualifications satisfactory to the MSAS (through the UEC). 20. Poverty Category. The proposed project specifically targets poverty by increasing the efficiency and quality of services of public hospitals, which are primarily used by the poor, and by helping to reduce the pervasive subsidy of the OSs and the private sector by improving patient identification and billing systems in public hospitals. 21. Environmental Aspects. The proposed project would improve medical waste disposal systems in the 15 pilot hospitals under Component If. The current environmental rating of the project is "B". Under Component I, the project includes a study to review relevant legislation and institutional framework on medical waste management. Under Component IL, management of medical waste is included as part of the institutional development of the 15 pilot hospitals. 22. Program Objective Categories. Within the broad category of human resource development, the project's objectives are to promote more effective health policies and to reduce poverty.  - 8 - 23. Participatory Approach. During project preparation, special attention was given to ensure the support of key stakeholders, particularly of the provincial governments (and the MCBA), the MOE and professional associations. In this respect, the project preparation team consisted of representatives from the national and jurisdictional level and the MOE. Special attention was given to ensure support of the MOE. Moreover, during appraisal, the Buenos Aires Medical Association endorsed the proposed project. 24. Expected Benefits. The main benefit of the proposed project would be to help the Government implement its objective of rationalizing sector spending by strengthening policy-making and improving service-delivery capacity. First, by strengthening policy-making through definition of specific short- and medium-term strategies and actions aimed at furthering sector reform (Component 1), the proposed project would set the stage and would provide the technical tools for an in-depth transformation of the sector. Second, by supporting the institutional development of 15 pilot public hospitals and guiding their transformation into HPAs, the proposed project would establish a new and more efficient delivery model to be replicated nationwide. Improving public hospitals' management through their transformation into independent trusts is a priority for the reform of the Argentine Health Sector. Such transfornation will introduce the required incentives to significantly improve productive efficiency in the public hospitals, which constitute about 80% of public health expenditures in the country. The project will, inter alia, increase cost- recovery, allow for more flexibility in the utilization of resources by hospital managers, reduce unnecessary utilization of hospital beds, and increase their productivity. At the same time, the change of the managerial model for the public hospitals will allow for a complete public-private integration in the provision of health services in the Argentine Republic in the near future. 25. Risks and Safeguards. The two principal risks of the proposed project are: a lack of future political commitment to reform in the health sector, and project implementation demands outstripping the managerial capacity of the MSAS, the Provincial Ministries, and the MCBA Health Secretariat. Political commitment is particularly difficult to gauge in the case of Argentina's health care sector, given the number and variety of interest groups involved (e.g., national and provincial governments, unions, professional associations and private sector institutions). While it is not possible to guarantee support for the project by all stakeholders, risks related to the political sustainability of the project have been minimized by: the attention given during preparation to securing the support of key stakeholders, particularly of the provincial governments (and MCBA), the MOE and some professional associations; and by a project design which is not overly ambitious, has pilot and demonstration features and, through specific and operational studies, focuses on gradually building the sector's knowledge base for reform. With regard to the project's demands outstripping the MSAS's managerial capacity, the risk would be minimized by: (i) full-time project units (UEC and UEPs) that have successfully managed preparation and are familiar with the Bank's guidelines, following the administration of an advance from the PPF; and (ui) annual and Mid-Term Reviews to assess implementation progress and adjust the pace and scope of implementation as needed. James D. Wolfensohn President Washington, D.C. Attachments July 5, 1995  Schedule A ARGENTINA PROVINCIAL HEALTH SECTOR DEVELOPMENT PROJECT Table 1: Detailed Project Cost Summary Local Foreign Total % Foreign % of Total -USS million- Exchange Base Costs Base Costs L Formulation of Policy for Reform I Design for the Separation of the Health Service Provision and Financing Functions at the Provincial Level 0.11 0.19 0.30 62.00 0.00 2 SurveyofHealthServices 1.01 0.49 1.50 33.00 1.00 3 Health Care Priorities for Argentina 0.29 0.20 0.49 40.00 0.00 4 DesignofPaymentSystemforHospitals 0.41 1.10 1.51 73.00 1.00 5 Design of an Identification System for Health Insurance Beneficiaries 0.24 0.16 0.40 40.00 0.00 6 RegulatoryFrameworkforPrivateInsurersandProviders 0.18 0.31 0.49 64.00 0.00 7 Quality Assurance 0.09 0.21 0.30 70.00 0.00 8 Provincial "Obras Sociales' Reform 0.38 1.02 1.40 73.00 1.00 9 AIDS 0.07 0.45 0.52 86.00 0.00 10 Preinvestment Studies 0.08 0.53 0.61 87.00 0.00 Subtotal 2.86 4.66 7.52 62.00 6.00 IL Pilot Implementation of Autonomous Hospitals 1 lnfrastructure Upgrading 32.65 50.14 82.79 61.00 64.00 2 Institutional Development 18.25 14.71 32.96 45.00 25.00 Subtotal 50.90 64.85 115.75 56.00 89.00 IIL Dissemination of Reform Initiatives I Technical Assistance 1.95 0.79 2.74 29.00 2.00 2 Training 0.21 3.27 3.48 94.00 3.00 Subtotal 2.16 4.06 6.22 65.00 5.00 Total Base Costs 55.92 73.59 129.50 57.00 100.00 Contingencies Physical Contingencies 3.42 4.45 7.88 57.00 6.00 Price Contingencies 3.15 4.17 7.32 57.00 6.00 Total Contingencies 6.57 8.62 15.20 57.00 12.00 Total Project Cost 62.49 82.21 144.70 57.00 112.00 N.B. Totals may not sum exactly due to rounding.  -10- Schedule B ARGENTINA PROVINCIAL HEALTH DEVELOPMENT PROJECT Summary of Procurement Arrangements (US$ million equivalent) Procurement Method Procurement Element ICB NCB Other Total Cost 1. Civil Works 59.8 3.2a1 63.0 (41.9) (2.2) (44.1) 2. Goods Computer Hardware and Software 12.0 12.0 (8.4) (8.4) Vehicles 0.51 0.5 (0.4) (0.4) Office Equipment and Furniture 0.11' 0.1 (0.1) (0.1) Medical Equipment 7.0 10.2 11.4bl 28.6 (4.9) (7.1) (8.0) (20.0) 3. Consulting Services and Training 39.3' 39.3 (27.3) (27.3) 4. PPF Refinancing 1.15 1.15 (1.2) (1.2) TOTAL 19.0 70.0 55.7 144.7 (13.3) (49.0) (39.2) (101.4) a/ Includes lump-sum fixed contracts on the basis of comparisons of at least 3 price proposals bl Includes Local and International Shopping (up to US$1.4 million equivalent) and LIB for eligible medical equipment (up to US$10.0 million equivalent) c/ Consulting Services Note: ICB = International Competitive Bidding NCB = National Competitive Bidding LIB = Limited International Bidding Numbers in parentheses reflect Bank financing.  -11- ARGENTINA PROVINCIAL HEALTH SECTOR DEVELOPMENT PROJECT Disbursement Forecast DISBURSEMENT (USS million) Cumulative IBRD Fiscal Year Semester Cumulative as Percent Project and Semester of Total Semester FY96 2nd (Jan.-Jun. '96) 5.2 5.2 5 1 FY97 1st (Jul.-Dec. '96) 5.2 10.4 10 2 2nd (Jan.-Jun.'97) 14.8 25.2 25 3 FY98 1st (Jul.-Dec. '97) 14.8 40.0 39 4 2nd (Jan.-Jun. '98) 16.7 56.7 56 5 FY99 1st (Jul.-Dec. '98) 16.7 73.4 72 6 2nd (Jan.-Jun. '99) 10.5 83.9 83 7 FY00 1st (Jul.-Dec. '99) 10.5 94.4 93 8 2nd (Jan.-Jun. '00) 3.5 97.9 97 9 FY01 1st (Jul.-Dec. '00) 3.5 101.4 100 10 Closing Date: June 30, 2001 *Includes USS1.15 million (PPF), USS2.0 million (Retroactive Financing), and USS2.0 million (Initial Special Account Allocation).  - 12- ARGENTINA PROVINCIAL HEALTH SECTOR DEVELOPMENT PROJECT Disbursement Allocations % of Amount Expenditures Category (US$ equivalent) Financed 1. Works 37,500,000 70 a/ 2. Goods 70 a/ (a) Medical Equipment 17,000,000 (b) Computer Hardware and Software 7,100,000 (c) Office Equipment and Furniture 100,000 (d) Vehicles 300,000 3. Consultants' Services and 70 a/ Training 23,000,000 4. PPF Refinancing 1,150,000 5. Unallocated 15,250,000 TOTAL 101,400,000 at Percentage of total expenditures  -13- Schedule C ARGENTINA PROVINCIAL HEALTH SECTOR DEVELOPMENT PROJECT Timetable of Key Project Processing Events (a) Time taken to prepare: 24 months (b) Prepared by: Argentine Government, Ministry of Health and Social Action, with the assistance of the Bank (LA1HR) (c) First Bank Mission: July 1994 (d) Appraisal Mission Departure: March 1995 (e) Negotiations: May 1995 (f) Planned Date of Effectiveness October 1995 (g) List of relevant ICRs, PPARs Report No. 6555 and Bank evaluations: Population, Health and Nutrition Sector Review - Argentina, 1987 Report No. 14410 ICR: Argentina - Loan 2984-AR Social Sector Management Technical Assistance Project, May 1995  -14- Schedule D THE STATUS OF BANK GROUP OPERATIONS IN ARGENTINA STATEMENT OF BANK LOANS (as of March 31, 1995) (US$ million) Loan Fiscal AMOUNT (less UNDISBURSED Number Year Borrower Purpose cancellations) Fully disbursed loans (42) 5,033.3 0.0 of which SAL/SECAL/Debt Reduction loans: 2675 1986 Argentina Agriculture Sector 350.0 2815 1987 Argentina Trade Policy 496.0 2996 1989 Argentina Trade Policy II 300.0 3291 1991 Argentina Public Enterprise Reform 300.0 3394 1992 Argentina Public Sector Reform 325.0 3666 1993 Argentina DDSR Support 450.0 3568 1993 Argentina Financial Sector Adjustment 400.0 2641 1986 Argentina Water Supply 44.8 8.5 2864 1987 Argentina Power Distribution 276.0 84.9 2920 1988 Argentina Municipal Development 120.0 10.1 2984 1989 Argentina Social Sector 28.0 0.1 3280 1991 Argentina Provincial Development 200.0 141.1 3281 1991 Argentina Water Supply 100.0 92.8 3292 1991 Argentina PEREL 23.0 1.3 3297 1991 Argentina Agricultural Services 33.5 13.9 3362 1991 Argentina Pub Sectr Reform T.A. 23.0 7.9 3460 1992 Argentina Tax Administration II 20.0 4.6 3520 1993 Argentina Yacyreta II 300.0 28.1 3521 1993 Argentina Flood Rehab 170.0 82.7 *3556 1993 Argentina Pub Entwprise Ref II 300.0 0.03 3611 1993 Argentina Road Maintenance & Rehab 340.0 246.8 3643 1994 Argentina Maternal & Child Health 100.0 86.4 3709 1 / 1994 Argentina Capital Markets 600.0 500.0 3710 1994 Argentina Capital Markets TA 8.5 7.8 3794 2/ 1995 Argentina Secondary Education I 190.0 190.0 03836 1995 Argendne Provincil Reforn 300.0 240.0 3860 2/ 1995 Argentina Municipal Development II 210.0 210.0 TOTAL 8,320.0 of which has been repaid 2,481.8 TOTAL NOW OUTSTANDING 5,838.2 AMOUNT SOLD 12.8 of which has been repaid 12.8 TOTAL NOW HELD BY BANK AND IDA 5,82S 4 TOTAL UNDISBURSED 1930 0 *Disbursing SECAL, SAL or Debt Reducion Loan 1/ Not yet affective 2/ Not yet signed. 10-Apr.95  -15- ARGENTINA STATEMENT OF IFC INVESTMENTS as at March 31. 1995 (US$ Millions) Origir] Grosa Commitments Held Held by Undi bursed F-ci Year IFC IFC Pustici- by Partici- (lncluding Commited Obligor Type of Busines Loan Equity pant Total IFC pants Ptcipent) 1960i95 Acindas S A. Steel Products 27.94 - 20.73 48.67 25.00 - 15.00 1960 a/ PapeleraRioParanaS.A. PulpandPaper 3.00 - - 3.00 - - 1961 a/ Fadesa SA. Motor Veh. & Accessores 1 23 - 0.28 1 50 - 1962 a/ Pass SAIC Petrochemicals 3 05 - - 3.05 - 1 965/72 a/ Celulosa Argentina Pulp and Paper 8 25 - 4.25 12.50 - 1969 a/ Editorial Codex S A. Printing and Publishng 5.00 1 60 040 7.00 - 1969/75 a/ DalmineSidercaSAIC IronandSteel 14.75 - 2.25 17.00 - 1971/73 a/ Calera Avellaneda S.A Cement 5.50 - - 5.50 - 1977/84186/88 AlpargabsSAIC Textiles andShoes 62.93 500 36.50 104.43 34.22 29.00 1977/85 a! Soyex SA. Food and Food Process 21.00 - - 21.00 - - 1978/81//82/87/93/94 Juan MinetbS.A. Cement 4400 - 67.50 111.50 951 9.29 1978/85/87/88/91 a/ Massun S.A. PulpandPaper 25.85 4.25 3.00 32.90 - - 1979/82/87/92 a/ Ipako SA. Petrochemicals 21.00 1.15 9.00 31.15 - - 1979/83/84 a/ Alpesca SA. Food & Food Process 5 20 1.61 - 6.81 - - 1984/86 Petroquimica Cuyo S.A. Chemicals & Petrochem. 21.00 4 00 21.09 46.09 3.52 4 25 - 1986 a! Atanor S A. Chemicals 7 00 1.00 - 8.00 - - - 1988 Ropa-saSadiew Capital Markets - 0.05 - 0.05 0.05 - 1984/87 Sadicar Capital Markets - 2.00 - 2.00 0.43 - - 1986 ROB-Cattorini General manufacturng - - - 0.00 0.18 - 1986 ROB-Benvenuto Food & agribusiness - - - 0.00 - - 1986 ROB-Boldt limber, pulp & paper - - - 0.00 - - 1988 ROB-Clave Plast General manulacturng - - - 0.00 - - 1986 ROB-Cuyo General manutacturng - - - 0.00 - - 1986 ROB-Gaverante Industtal services - - - 0.00 - - 1988 ROB-Klaukol Cement - - - 0.00 - - 1986 ROB-Labelcor Food & agribusiness - - - 0.00 - - 1986 ROB-Longvie General manutacturrg - - - 0.00 0.90 - 1986 ROB-Pilar General manulacturng - - - 0.00 019 - i 986 ROB-Sudamericana lndustrial equipment - - - 0.00 0.21 - 1986 ROB-St.Ursula Food & agribusiness - - - 0.00 - - 1986 ROB-Stani Food &agribusiness - - - 0.00 - - 198e ROB-Tage Industrial services - - - 0.00 - - 1986 ROB-Dario Timber. pulp&paper - - - 0.00 0.09 - 1988 ROB-Piedre Mining - - - 0.00 0.0e - 1986/89/91/95 Banco Roberts S.A. Captal Markets 48.00 - - 48.00 20.00 - 1987 a/ Garovaglio y Zorraqumn General Manufacturing 13.00 - - 13.00 - - 1987/90 Hira Oil Crude Petrol. & Nat. Gas 80.00 - 27.60 107.60 0.38 - 1987/90/91 Terminal 6 S.A. Port Facilites 12.50 0.00 0.00 12.50 500 - i988 al Asbra CAPSA Lindero Energy 12.38 - - 12.38 - - 1988 a/ Bridas S.A.P.I.C. Energy 20.53 - - 20.53 198.8 Arcor SAIC General Manufacturing 12.00 - - 12.00 1.00 - 1988 SGN-Colortex Texbles - - - 0.00 0.33 - 1988 BGN-Estrella General Manufacturing - - - 0.00 - - 1988 BGN -Interpack limber. pulp & paper - - - 0.00 0.50 - 1988 BGN-Noroeste Food & agribusiness - - - 0.00 0.17 - 1988 BGN-CiUsa Textles - - - 000 0.07 - 1988 BGN-Moldeada Timber-pulp & paper - - - 0.00 0.33 - 1988 BGN -Oftalmologic Timber-pulp & paper - - - 0.00 - - 1988 BGN -San Sebasban Food & agribusiness - - - 0.00 0.33 - 1988 BGN -Tevycom Industral equipment - - - 0.00 0.10 - 1988 BGN-Valley Food &agribusiness - - - 0.00 017 - 1988 BGN-Vandenlil Textiles - - - 0.00 0.17 - 1988/89 BGN-Flichman General Manufacturing - - - 0.00 0.43 - 1988/89 Banco General de Negocios AL Dev. Finance 20.00 - - 20.00 - - 1988/92 a/ Chirets Oil Chemicals & Pebrochem. - 862 - 8.62 - - 1988192 Banco Rio de la Plate Capital Markets 50.00 - - 50.00 32.00 - 7.53 1988/93/94 Bung. y Born Food and Food Process 63.00 - 57.50 120.50 19.00 57 50 - 1988/93 BGN-Longvie General manutacturrig - - - 0.00 0.13 - 1989 a/ ArgentinelnvestrnentCompany Securities/Financallnst. - 2.00 - 2.00 - - 1989 a/ Chihudos Petroleum Energy - 4 98 - 4 98 - - 1989 Banco Frances Dev. Finance 15.00 - - 15.00 10.91 - 1989 ROB-Carboclor Chemicals & petrochem - - - 0.00 0.14 - 1989 BGN-Concosud Industral services - - - 0.00 0.33 - 1989 ROB-Ciervos Food &agribusiness - - - 0.00 - - 1989 ROB-Comesi General manutacturng - - - 0.00 0.75 - 1989 ROB-Maleic Chemicals & petrochem - - - 0.00 - - 1989 ROB-Malteria Food & agribusiness - - - 0.00 - - 1989 Com. General de Inversones Financial Services - 010 - 0.10 0.01 - 1989 ROB-Fracchia Industlraservices - - - 0.00 0.49 - 1989 ROS-Lauril Chemicals & pefrochem - - - 0.00 0.28 - 1989 ROB-Inta Textles - - - 0.00 0.75 - 1989 ROB-Masoprano limbs-pulp & paper - - - 0.00 0.10 - 1989 BGN-Parafina Chernicals&pebrochem - - - 0.00 1.25 - 1989 BGN-Pastoril Food & agribusiness - - 0 00 036 - 1989 BGN-Genaro Food & agribusiness - - 0.00 1 36 - 1989/92 Astba CAPSA Energy 50.00 - 43.00 93.00 24.80 28.67 -  -16- ARGENTINA STATEMENT OF IFC INVESTMENTS as of March 31, 1 995 (USS Millions) Origirl Gros Commitmerts Held Held by Undiburrsed Fiscal Yer IFC IFC Parbci- by Partici- (Including Committed Obligor Type of Businesa Loan Equity pants Total IFC pants Parbcipsnts) 1989/93 BGN-Bolland Tourism - - - 0.00 0.40 - 1990 EGN-Algodonera Texbles - - - 0.00 0 54 - 1990 Corporacion do Inversiones y Privatzacion SA Financia Services - 0.08 - 0.08 0.08 - 1990 BGN-Frogotoba Food & agribusiness - - - 0.00 0.25 - 1990 BGN-Willmor Food & agribusiness - - - 0.00 1.36 - 1990/95 Petroken Petroquimica Chemicals & Perochem. 40.00 - 11.00 51.00 35.67 7.33 10.00 1991 Banco dis Credito Argentino Financial Services 10.00 - - 10.00 7.14 - 1991 ROB-Guitford Textles - - - 0.00 0.47 - 1991 ROB-Jugos Fod & Agribusiness - - - 0.00 0.33 - 1991 ROB-interpack Timber,pulp&paper - - - 0.00 1.00 - 1991 ROB-Surfactan Chemicals & petrochem - - - 0.00 0.21 - 1991 BGN-TSR Indusbiul equipment - - - 0.00 0.38 - 1992 Frigorifxo Rioplatense Fod&Agribusiness 12.00 1.00 6.00 19.00 10.33 5.00 2.00 1992 MBA Sociedad de Bolsa SA Capital Markets - 0.18 - 0.18 0.18 - 1992 OlDsginosa Oeste Sunflower Seed Agribus. 20.00 - 15.00 35.00 18.93 12.50 1992 Polisur SM Chemicals & Petrochem. - 7.00 - 7.00 7.00 - 1992/93 Pefrolera ArgentiruSanJorge Energy 15.00 27.00 35.00 77.00 40.75 32.08 25.18 1993 Alto Parana SA. limber, pulp and paper - - - 0.00 19.47 - 1993 Eridas SAPIC Energy 35.00 15.00 50.00 110.00 50.00 55.00 - 1993 CadipsaS.A. Energy 15.00 5.00 20.00 40.00 20.00 13.00 920 1993 BGN-Capri Food&agribusiness - - - 0.00 1.00 - 1993 ROB-Emprigas Industral services - - - 0.00 1.13 - 1993 Ferroexpreso Pampeano SAC Industrrl Equipment 13.00 - 20.00 33.00 13.00 18.53 4.60 1993 ROB-Alimenticia Food & agribusiness - - - 0.00 0.83 - 199.3 Malteria Pampa SA. Food & Agribusiness 12.00 - 12.00 24.00 12.00 12.00 1993 ROB-Mendoz General manufacturrig - - - 0.00 1.13 - - 1993 Nusvo Central Argentino SA Railroad Equipment 10.00 3.00 15.00 28.00 13.00 - 1993/94 Molinos Rio de la Plata Food & Agribusiness - 3.00 - 3.00 7.82 - 1994 Banco General de Negocios Dev. Finarce 15.00 - - 15.00 15.00 - 1994 Cerveceria y Malteria Ouilmes Food & Agribusiness 15.00 - 15.00 30.00 15.00 15.00 - 1994 CIA Gen Combustible Crude Petroleum 25.00 15.00 40.00 80.00 40.00 40.00 - 1994 Empresa Distrbuidora Industral Services 45.00 - 128.00 173.00 45.00 128.00 - 1994 Quieral Chemicals & Petrochem. - - - 0.00 - - 1994 BGN-Ferrum Cement & construc mat - - - 0.00 1.50 - 1994 Masisa-Argentina SA. Forest Products 11.00 - - 11.00 11.00 - 1994 Arg.Equity lnvestmnert I Limited Financial Services - 4.00 - 4.00 4.00 - 1994 Yacylec Industrial Serfices 20.00 - 45.00 65.00 20.00 45.00 - 1995 Aceitwra Food&Agribusiness 15.00 10.00 15.00 40.00 25.00 15.00 15.00 1995 Mastellone Hermanos SA. Food & Agribusiness 40.00 - 35.00 75.00 40.00 - 1995 Maxima SA. AFJP Financial Services - 10.19 - 10.19 10.19 - 1995 La Buenos Aires Vida Financial Services - 2.89 - 2.89 2.89 - 0.71 1995 La Buenos Aires Retiro Financial Services - 1 17 - 1 17 1.17 - 0.53 1995 KloppeiCaldero Food &agribusiness 6.00 - - 6.00 6.00 - 1995 Aguas Infrastructure 38.00 700 134.50 179.50 45.00 134.50 52.95 1995 Compania ELaboradora de Productos Alimenticios SA. Food & agribusiness 15 00 - 6.00 21.00 15.00 6.00 - 1995 Robrts Argenbna Investment Capital Fund (AICF) Financial Services - 20.00 - 20.00 20.00 - 17.73 1995 Robets Argentina Investment Fund Manager Financial Services - 0.15 - 0.15 0.15 - 0.13 1995 Soema Holding Company 24.99 15.00 60.01 100.00 39.99 - 24.99 1995 Cadesa Supermarkets 28.00 - - 28.00 28.00 - 20.00 TrSf Grss Commitments bl 1152.99 181.00 95.581 2299.60 Less: Cancelations, Terminations, Repayment & Sabls 481.57 6.19 297.96 785.72 TotS Commibnents Now Held c/ 671.43 174.82 667.65 1,513.89 840.24 867.65 205.56 Pending Commitments: AECSA 20 00 - 61.00 81.00 Empresa Distrbuidora Industrial Services - - 8.00 8.00 Gasinvest Infrastructure - 20.00 - 20.00 Nahuelsat Infrastructure 30.00 5 00 - 35.00 Sancor Food & agribusiness 20.00 20.00 30.00 70.00 Transconor Infrasructure 25.00 - 80.00 105.00 Tucuman Infrastructure - 0.30 - 0.30 sub-total 95.00 45.30 179.00 319.30 TotS Commtments Held and Pending Commiret 786.43 220.12 84a.65 1,833.19 Toat Undsfbtrsad Commitments 92.02 44.28 89025 205.58 aj Investments which have been fully cancelled, terminated. written-off. sold, redeemed or repaid. b/ Gross Commitments consist of approved and signed projects. c/ Held Commitments consist of disbursed and undisbursed investmernts.  IBRD 25587 70 0 BOLIVIA 60