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Document of

The World BankrILE cOPY

FOR OFFICIAL USE ONLY

Report No. 6837-BR

STAFF APPRAISAL REPORT

BRAZIL

NORTHEAST ENDEMIC DISEASE CONTROL PROJECT

January 19, 1988

Brazil Country Department

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

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CURRENCY EOUIVALENTS

Currency Unit = CruzadoCZ$1.00 = US$ .056 (March 1987)US$1.00 = CZ$17.9 (March 1987)

FISCAL YEAR

January 1 - December 31

FOR OFFICIAL USE ONLY

BRAZCIL

NORTHEAST ENDMKIC DISUSE COWTROL PROJECT

&SAFF APPAI SAL REPORT

Table of Contes-to

LOANAND PROJECT SUMMRY .... ............... iii

GLOSSARY OF ACRONYMS . . . . . . . . . . . . . . . . . . . . vi

DEFINITIONS . . . . . * . .*. ......... vii

1. COUNTRY RAM DEVLOPMET ................... 1

A. Population, Health, and Nutrition . . . . . . . . . . . 1B. The Major Enuewic Diseases . I..... .O.S... 1C. Institut-ons, Policies and Resources for ndui; Diseasea

Control . . . . . . .. . . . . . . . . . . . a . . 3Do Issues . . . . . . . a . . a * a * * * a * * . . * * * * 6S. Country and Bank Goals and Sector Lending Strategy . . . 6

II. THEP zCET *0 * ** . . . *0 * * * * .. *...... . . 7

A. Project Concept and Objectives . *. . .. . . 7B. Project Areas 000 *..* * .. ee. * 0 8C. Main Features a * .........*....... .. . . . . . 8D. DetailedDescription.................. 10

III. PROJBCT COSTS AND 7IIANCING .*.. . ............ 16

A. Project Costs .... . . . . . . a * * * * . * * * * . 16B. Project linancingPlan................. 17Co Procurement ...... . . . . . . . . . . . . a a . 18D. Disbursements . . . . . . . ... *. . ... . 21I. Accounts and Audits .. ................. 22

This report is based on the findings of an appraisal mission consisting ofDr. 0. Echeverri (Mission Leader) and Messrs. A. Zufliga, and 1. Coll(Consultants), who visited Brasil in August 1987.

Thb document ha a rstcedk dbutn and may be ud by r4*eatsol In te pefonce nof tl okic dutis Its connts my n oterwI be dicosd wiout Wodd Bank wathodatlon

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IV. PtOJECT ORGANIZATION AND INPLMEUTATION . . .......... 22

Project Organization and Managemeat . . . . . . . . . . . . 22Iustitutional Streugtheniag of SUCAW . . . . , . , . . . . . 25Status of Project Preparation . . . . .. ,....... 26

V. PROJUCT BEN FITS AND RISKS . . . ............... 26

A. Realtb uad Snviroumental Impact . . . . ..... 26B. ProjectBisks .... *. . ....... . . . . .R. 27

VI. RECOMMENDATIONS . . . . . . . . . . . . . * e * * * . 28

1 - Epidemiological Data on Northeast Endemic Diseases2 - Safe Vse of Insecticides3 - Commumity MobilizLtion4 - Project Implementation Data5 - AIDS component6 - Project Costs7 - Schedules of Disbursements8 - SUCAM and Project Unit organizational Cbarts9 - Selected Documents and Data Available in the Project Pile

- IIRD 20434

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BRAZIL

NORTHEAST IDEMIC DISEASE CONTROL PROJ8CT

STAFF APPRAISAL REPORT

LOAN AND PROJNCT SJMK

Borrower: Federative Republic of Brazil

Project Executing Ministry of Health - KOH, Superintendency of Public HealthAgency: Campaigns - SUCAM.

Amounts US$109.0 million equivalent

Term:s Repayment in 15 years. including 3 years of grace. at theBank's standard variable interest rate.

trolect The project's main objective is to control three majorObjectives: disesases (Chagas' disease, schistosomiasis. and

leielbaniasis) by reducing the prevalence and intensity ofhuman infection in the population at risk of Brazil'sNortheast, and to improve health status and productivity. Anadditional o1jective is to support MOB activities to reducethe occurrence of AIDS cases.

Project The project includes five components: a) Prevention andDescription: Centrol of dimnse transmiasiom, involving epidemiological

mapping. surveys, screening for disease. treatment of cases.and vector control; b) Cb ity Mobilization. includingorganization of community groups for participation indisease control activities. i.e.. elimination of vectors; c)Operational Research. including well identified studiesaimed at solving practical problems in the control ofChagas, schistosomiasis. and leishmaniasis; d) InstitutionalDbnelo aunt. including the strengthening of SUCAM'sadministration and human resources; improving its dataprocessing capabilities; establishing an Information,Education, Communication unit. IEC; and construction offacilities for the Regional Directorates; e) JIDS Control.including a mass media campaign on AIDS prevention, testingof blood supply and donors, and health staff training.

Beneficiaries: Approximately 30 million at-risk people--small farmers, poorpeasants and urban families in the ten states of theNortheast-will benefit from the project.

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Project Three major benefits are ezpected from the project: (a) aBenefits: substantial reduction of the risk of contracting Chagas'

disease. schistosomiasis and leishmatiasis and thussubstantial reduction of morbidity and lisability due tothese diseases; (b) savings on medical and hospital carecosts and gains in productivity of the labor force: and (c)improvements in SUCAM's management, administration, andefficiency of endemic disease control programs. with a spillover effects in the efficiency of controlling other endemicdiseases such as rabies. trachoma, malaria etc.

Project Risks: Low salaries, and harsh and at times dangerous workingconditions may hamper SUCAM's efforts to contract therequired staff to carry out the project field operations ina timely fashion. These risks have been specificallyaddressed in the project design. through hiring of staff bymunicipalities, thus allowing for payment of better wages;financing wages and improving per diems for field work,which would make the Job more attractive; and providing fortraining on safe use of pesticides.

Estimated Costs:

ZPAML - MIM BWC DISMS OCR PIOJ

Clzmms of UB)

~~~~~~~~1U v-= r T OE~L~ FM= ENI X Tmm I - QmI I 1L~CL I ~Q4 I ¶UIL I EmuI= am M

I I I I I Ier3 ~~~~~( WOM 3,0 1 735. M1 1 4691 12

II. CDDKkh5 W CnQ A 1FiECSDSIQI 33,069.7!1 73,508. h 156,573.1 1 46.9S 78.2 13 -3 I I t I IIIn. mOImJII Pn-nM 1 7,673.6 1 2,909.3 1 10,58.9 1 27.23S 5.3 1I . I 1 I I .I IIIJ U ENL EE9bRl 1 1,275.0 1 225.0 1 1,500.0 1 15.A(I 0.7 1I 1 1 II I Iliv. VISE niL DIsa I 2D,l1S.8 l 3,570.6 3 23,754.4 1 15.CV 11.9 1

IV. CONW & PHffUiC iW AMDS I 6,129.9 1 1,647.6 l 7,777.5 1 21.221 3.9 1I . I I 3 -I I - -flurL BW COr I 118,311.3 1 1,8§5.9 I 20D,l7.9 1 40.9 1 100.01I I I I I I I!PI IL CtIC 1I 6,455.0 1 4,665.1 1 11,110.0 1 41.9 1 5.0 1Imw CDiDNE S I 3,826.8 1 2,922.4 1 6,749.2 1 43.3 1 3.2 1

3 1 1 1 3 I IIITJW. PM=JCF c4sr 1 12,593.1 1 89,433.4 1 21B.087.1 1 41.0 1 108.2 t

I I I I I I I

* ~~~~~- v

Finacing Plan:Local Foreisn Total-U- 86 million-

Federal Government 109.0 - 109.0TiBD 19.6 89.4 109.0

TOTAL 128.6 89.4 218.0= ==

Estimated Disbursements:

Bank PT: 1988 1989 1990 1991 1992 1993

Annual 8.0 16.5 25.5 26.0 22.0 11.0Cumulative 8.0 24.5 50.0 76.0 98.0 109.0

Estimated Project Completion Date: June 30, 1993

Estimated Rate of Returns Not applicable

Staff Appraisal Reports No. 6837 BR

IBRD 20434

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LO8SARY OF ACRONYMS

CEMI Central de IfedicamentosDrugs Distribution Center

CIPLAN Interministerial Committee for Planning and Coordination

COPLAN Coordenadoria de PlanejamentoPlauning Coordination unit

DIRuS Diretorias Regionais -BUCAMRegional Health Directorates

FIOCRUZ Funda9ao Inastituto Osvaldo CruzOswaldo Cruz Institute Foundation

FSE1P Fundagto Servi;os de Safide PgblicaFoundation for Public Health Services

IVAN Instituto Nacional de Alimentalo, e Nutrig8oNational Institute of Food and Nutrition

1AHP8 lstituto Nac4t,il de Assistencia Medica e Previdencia SocialNational Institute for Social Security and Medical Assistance

MOD Ministry of Health

QPAS Ministerio da Previdencia e Assistencia SocialMinistry of Social Security and Welfare

PARD Panamerican Health Organization

UES 8ecretaria de Zstado da SafdeState Secretariats of Health

SOPF Secretaria de Or9amento y Programa9to FinanceiraSecretariat of Budgeting and Financial Programming -MOR

SUCAM Superintendencia de Campashas de Saedd PEblicaSuperintendeuce for Public Health Campaigns

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DEFINITIONS

Crude Birth Rate : Number of births per 1.000 population in agiven year.

Crude Death Rate : Number of deaths per 1,000 population in agiven year.

Incidence Rate : The number of persons contracting a diseaseas a proportion of the population at risk,per unit of time usually expressed per 1,000persons per year.

Infant Mortality Rate : The number of deaths of infants under oneyear of age in a given year per 1,000 livebirths in that year.

Life Expectancy at Birth : The average number of years an infant wouldlive if the current age/sex-specificmortality trends prevailing at the time ofbirth were to continue.

Maternal Mortality Rate : The number of deaths to women who die due topregnancy and childbearing complications in agiven year per 100,000 live births in thatyear.

Morbidity : The frequency of disease and illness in apopulation.

Prevalence Rate : The number of persons having a particulardisease at a given point in time perpopulation at risk. Usually expressed per1,000 persons per year.

Rate of Natural Increase : The rate at which a population is increasing(or decreasing) in a given year due to asurplus (or deficit) or births over deaths,expressed as a percentage of the totalpopulation.

Total Fertility Rate : The average number of children that would beborn alive to a woman during her lifetime ifshe were to pass through her childbearingyears conforming to the age-specificfertility rates of a given year.

NORTREAT ENDUIIC DISAUSE CONTROL PROJECT

I. COUNTRY REALTE DEVELOPMENT

A. Population. HPalth. and Nutritiou Status

1.01 Brazil's population of about 136 million (1986) is young andunevenly spread over the country's 8.5 million km2, with densities rangingfrom two inhabitants per km2 in the state of Amazonas to 56 per km2 in theSoutheast. The popula%Aon growth rate has declined from 2.52 (1965-73) to2.3% in the 1974-83 decade, and is expected to drop to 1.8 X by the year2000. Heavy migration (1.5 to 2 million per year) of rural poor to urbanareas affected all regions, including the Northeast, which doubled its urbanpopulation in the last 30 years. Total fertility declined from 6.1 in the1960s to 3.6 today.

1.02 In the country, health conditions are generally poor, consideringBrazil's overall level of development. Life expectancy at birth is 65years, or comparable to Colombia and Mexico, countries with lower per capitaincome than Brazil. Infant mortality (67 per 1000 live births), issignificantly higher than for Colombia and Mexico (48 and 50, respectively).In most parts of the country, diarrbea and respiratory infections are theleading causes of infant deaths, followed by perinatal causes.

1.03 In the Northeast (37.2 million inhabitants), health status is thelowest in the country as reflected by a low life expectancy at birth of 51-ears, an infant mortality rate of 125, and an exceptionally high prevalenceof endemic infectious diseases (sohistosomissis, Cbagas' disease,tuberculosis, letsbmeniasis, malaria and leprosy). About 471 of childrenunder 5 years of age have some degree of malnutrition, and 14% have moderateto severe malnutrition. In the 15-44 age group, the main causes of illnessand death are acute and endemic infectious diseases, accidents andviolence. Cbronic diseases, mainly heart diseases, cancer and stroke,account for the bulk of deaths in those over 45. Most of these healthproblems (except endemic diseases) are addressed in the Northeast BasicNealth Services-I and II Projects (the last under preparation).

B. The Major Endemic Diseases

1.04 A significant portion of Brazil's territory is located in thetropical zone, where the environment is rich in vectors and reservoirs ofcomunicable diseases, which have become endemic due to its pervasivepresence and to limited efficacious treatment and control measures. The so-called major vector-borne endemic diseases in Brazil are malaria, yellowfevsr, schistosomiasis, Chagas' disease, and leishmaniasis. Migration,opening of uew agricultural frontiers, and irrigation programs have greatlyincreased the transmission of these diseases. Overall, an estimated 352 ofNortheasternets suffer at any one time from one or more of these endemicdiseases and perhaps 651 of them are at risk. This morbidity greatly

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affects sehool attendance and labor productivity, and raises health carecosts.

1.05 Chagas' disease - American trypanosomiasis - is transmittedtbrough the biting and immediate defecatiou of infected triatomineae (ablood-sucking bug) on the bumau skin, and through infected bloodtransfusions and transplacental infection. Cardiac and cerebral involvementare life-threatening or fatal manifestations; main chronic sequelae arebeart failure and dilation of the esophagus and colon. Disease reservoirsinclude infected persons and many domestic and wild animals sucb as dogs,cats, pigs, bouse rats, and foxes. Four species of triatomineae vectorsexist in 2,000 municipios of the Amazon basin and the Northeast states.In rural Cear6, one out of 10 houses is infested with the vector bug(karbeirol. About 6 million chagasic patients exist in Brazil today, ofwbich 601 live in the Northeast; 15 million people are at risk ofcontracting the disease, without considering those at risk tbrough infectedblood transfusions (20,000 new cases per year) and transplacental infection(Annex 1, Table 1). In so Paulo and Minas Gerais, 31 to 5% of blooddonations come from chagasic patients. Outside the capital of Minas Gerais,one of the most disease-stricken states, 46Z of blood banks do not testdonors for Chagas' disease. Improvement of housing and living conditions isa long-term approach for the solution oi the problem. At present, in theabseuce of vaccines and drugs suitable for large-scale treatment of Chagas'disease, interruption of transmission must rely on vector and bloodtransfusion control, which have been proven successful in medium-scaletrials in Brazil and other countries.

1.06 Schistosomiasis, a parasitic disease, is acquired from watercontaining free-swiming larval forms (cercariae) which have developed insnails and penetrate the human skin. Liver fibrosis, splenic enlargement,ascites, and fatal intestinal obstruction are frequent complications inchronic infections. The relationship between the intensity of infection andsevere morbidity has been confirmed. Three species of snails (intermediaryhosts) exist along the Northeast Atlantic littoral And in other focal areasthroughout the country, where 30 million people are at risk of contractingthe disease (Anex 1, Table 4). About 8 to 10 million of Brasitians areinfected, and prevalence in the Northeast may range from 121 in Bahia to 231in Pernambuco. In some communities the prevalence reaches 801. During thelast twenty years, migration of infected persons within the country hasgreatly expanded the contaminatiou of soil and waters where snails exist,thus increasiAg the prevalence of schistosomiasis. The Brazilian Programfor Schistosomiasis Control has been successful in using chemotherapy andselective mollusciciding, but still, more knowledge on the epidemiology ofthe disease and widespread control measures are required to achieveeffective control of the disease.

1.07 Leishmaniasis, a dreadful protozoal disease, is transmittedthrough the biting of infected phlebotomies (sand flies). Main reservoirsinclude man dogs, and rodents. The main manifestations are ulceratinglesions which may be single or multiple involving the whole skin and themucocutaneous tissues (Cutaneous leishmaniasis); visceral involvement,

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especially of the liver and the spleen, if untrested, is usually fatal(visceral leishmaniasis or Kala azar). Both foams of the disease exist invast areas of Brazil, and in all Northeast ret a (Annex 1, Table 5). Thevector (sand fly) and main reservoir (infected dogs) exist throughout theNortheast, including many urban areas. A serologic survey shoved that allNortheast states have infected dogs, with a prevalence ranging from 12 inParaiba to 50% in Piaui (1985). Control activities were reduced in the lastdecade, thus leading to an alarming increase of new cases in recent years:between 1979 and 1985, the number of reported new cases has sky-rocketedfrom 3,243 to 16,200 per year; 95% of these cases were reported in theNortheast. Unreported new cases may easily triple this figure. Over 8million reople are estimated to be at risk. Safe and effective drugs andvaccines for large-scale treatment of leisemaniasis are not available.Interruption of transmission must rely p,rimarily on vector control, throughelimination of sand f'ies and domestic reservoirs such as infected dogs.

1.08 The Auto Imunue Deficiency Syndrome (AIDS) is a new fatal viraldisease that is creating a serious public health problem due to theexplosive propagation in the country. As of January 1987, Brazil reportedan increase of 267 new cases in only 4 months, bringing tho total number ofcases to 1,012 (the third largest figure by country, after USA and France).The risk of contracting the disease is particularly high in Sao Paulo and inRio de Janeiro where 20% (207) of AIDS reported cases have occurred viablood or plasma transfusions. The only effective measures available arepreventive and consist basically of wideepread education on ways to avoidcoutamination, and blood screening for AIDS carriers (Armex 5).

C. Institutions. Policies, and Resources for Endemic Disease Coantrol

1.09 The two major, public health sector institutions are the Ministryof Health (MOE) and the National Institute for Social Security and MedicalAssistance (INAHPS) which belongs to the Ministry of Social Security andWelfare (NPAS). MOR is responsible for setting national health policy andcollective health programs. MPAS is respousible for individual medicalcare, including hospital care for patients with endemic diseases. In theNortheast, the MOR has normative and legal authority and develops healthprograms in cooperation with State Secretariats of Health (88). TheSuperintendency of Public Realth Campaigns (SUCAK) is a semi-autonomousorganization under the MOR's authority (see para 1.11). Other NOR federalinstitutions involved in endemic disease control are the Special PublicHealth Services Foundation (ISISP) which under agreements with the MOR/SUCAKdevelop housing improvements and sanitation works in designated endemicareas; and the Osvaldo Cruz loundation (FIOCRUZ) involved in research,technical assistance, training, and laboratory support to SUCAN.

1.10 Poligies. The Government's interest in redressiug the criticalbealth situation of the Northeast is reflected in policies and strategiesaddressing basic health problems of the poor: (i) control of transmissiblediseases, especially endemic diseases and vaccine-preve.table ones; (ii)maternal and child care, including family planning; (iii) ambulatory and

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hospital care with priority for high risk groups. Nutrition and sanitationare priorities with separate strategies. The 1986-89 National DevelopmentPlan (NDP-I) has included the control of endemic diseases as a sectorpriority, particularly Chagas' disease, schistosomiasis, leishmaniasis, audmalaria. Improvement of surveillance activities, and expansion andmodernization of the Public Health Laboratories network, were alsoconsidered. Now, the Government has requested Bank support to address thegrowing and widespread problem of endemic diseases, through thestrengthening and expansion of the field operations and the institutionaldevelopment of SUCAN. Also, due to the fast growing AIDS problem, theGovernment requested support for the nationwide AIDS preventive progrim,including use of mass media, training, and blood testing for AIDS.

1.11 The Suverintendencv of Public fealth Campaitns - SUCAM: One ofthe MOR federal institutes is SUCAM, a well-organized semi-autonomoussuperintendency, in charge of endemic disease control. With about 30,000employees and a 1987 budget of US$200 million, SUCAh is characterized by thestrong loyalty aad dedication of its staff, its remarkable field experienceand work discipline, and the gsarit de corps, especially of the field staff.SGCAM is particularly active in the Northeast and Northwest. In the 70s,SUCAM implemented one of the world's most effective programs for controllingschistosomiasis (PUCE). SUCAM's good record in implementing disease controlprograms, in spite of resource constraints, ensures that it will efficientlyand effectively carry out this project. SUCAK's enabling regulations wereestablished by the Portaria (ministerial resolution) No. 161, May 1976; itscentral organization involves a Coordination unit and five Departments (seeAnnex 8, Chart 2). Planning, programming and budgeting is made in Brasiliaby the Planning, Budget and Control Coordination unit (COPLAN), frompropcials prepared by its 26 Regional Directorates in the state capitals andworked out with the 80 District Offices. The Department of Endemic DiseaseControl (DECEN) is responsible for the execution of all endemic diseasecontrol programs, and it has specific Divisions for Chagas' disease,schistosomiasis, and leishmaniasis control. The Department ofAdministration (DA) deals with all aspects of logistical support, includingtransport, communications, supplies, maintenance and repairs. The financialadministration is under a separate department (DAF), wbose organization andoperation follow the Ministry of Finauce's guidelines. The Department ofPersonnel (DP) deals with recruitment, selection, training, legal and careerdevelopment aspects, and is organized according to the Ministry of PublicAdministration's guidelines. The 26 Regional Directorates located at thestate capitals report to the Superintendent but are tecbnically subordinatedto DECEN.

1.12 Presently, the three main central management issues are: (a)obsolete logistics; (b) insufficient budget leading to weak logisticalsupport and obsolete equipment; and (c) administrative fragmentation amongvertically executed programs leading to duplicatiou of functions andunwieldy management. Also, the Regional Directorates confront seriousproblems: a) about 30-35X of the field staff for Chagas' disease,schistosomiasis and leishmaniasis control has been cut due to budgetconstraints, and other 35% of persomnel has been relocated to control the

vector of yellow fever; b) inadequate physical facilities for admiuistrativesupport, staff training, storage of supplies and equipment, maintenance andrepair of vehicles (para 1.13); c) inefficient accounting practices inmanagement of goods and supplies (requesting, purchasing, storing, ordering,distributing); (d) unsuitable data processing; (e) lack of audiovisualequipment for comunity mobilization and for supervision activities; and (f)recent appointment of regional directors based on political party groundsmore thau on managerial ability.

1.13 Facilities. SUCAM headqgarters are located in Brasilia. Aboutone half of the 24 buildings for regional directorates and one fifth of the80 district offices are rented. In the Nortbeast, seven of the tenbuildings for the regional directorates are rented houses, where officeequipment and space for laboratories, storage, and maintenance of vehiclesare limited.

1.14 Xanopwer: About 30,000 health workers are currently employed bySUCAM throughout the country. For each major endemic disease controlprogram, they are organized in teams of five guards (least skilled fieldworkers) under the leadership of a chief-guard; a group of five teams issubordinated to an inspector of endemic control, and a group of fiveinspectors is coumanded by a general inspector; a group of five generalinspectors is.subordinated to a professional in charge of a particulardisease control program (this organization provides for constant andeffective monitoring and supervision). These professionals are under themanagement of a regional director with office at the state capitals, andfinally, regional directors are subordinated to the SUCAN Superintendent.Recently, the outbreak of dengue and the threat of new cases of yellow feverin urban areas require4 the relocation of about 7,500 workers from otherSUCAN programs for emergency control operations, thus weakening theoperations in other fronts, particularly in schistosomiasis, leishmaniasis,and Chagas' disease control. The existing deficit of personnel to cover theNortheast with all control activities for major endemic diseases isestimated at about 9,500 field workers.

1.15 Pronram Coveraae: Endemic disease control programs bave beencurtailed in the past ten years. The Chagas control program covers the2,050 municipalities in 19 states identified as endemic areas by the Cbagas#first national serologic survey (1981); bowever, only 414 (202) of thosemunicipalities came under epidemiological surveillance in 1986, and morethan 60X of blood banks do not screen donors for Cbagas# disease due to lackof laboratory resources and technical staff. The estimated 6 millionchagasic patients are treated by the state or INAMPS health services. Nineof the 12 states with endemic schistosomissis belong to the Northeast, andnearly 602 of the endemic area (mostly in Bahia and Minas Gerais) is notcovered with the SUCAN's program due to lack of resources. Programactivities to control leishmaniasis vectors are restricted to small spotareas in the Northeast representing less than 25Z of the endemic area,despite the fact that vectors and reservoirs are found all over the region.Because of this insufficient coverage, the Government has requested

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financial assistance to ensure an effective control of these diseases in theNortheast.

1.16 Budgets: SUCAM's resources have been reduced by 302 during 1981-85, despite the steady increase of endemic diseases in the country. It isonly in the 1986-89 National Development Plan-I that increased financialprovisions have been made for endemic disease control in the amount ofUS$765 million for 1986-89. This is 3.52 of the total budget for the healthsector including INAMPS/14PAS and NOR. The four-year budget provisions foreach major disease control program are as follows: malaria control US$265.5million; yellow fever/dengue control US$204.4 million; Chagas' diseasecontrol US$192.7 million; schistosomiasis control US$52.1 million; and forother endemic diseases (leishmaniasis included) US$50.2 million. Theseresources only finance less than one half of a'l control programs necessaryto cover the population at risk living in endemic areas.

D. lsueo

1.17 Poor health status is one of the major issues confronted by theGovernment in the Northeast. Endemic diseases are responsible for aconsiderable number of sick and disabled people (paras. 1.05 to 1.08) withdirect impacts such as low labor productivity and high costs of medical andhospital care. Sustainabilitv of vector control activities and of screeningfor disease in target populations has become a critical issue in theNortheast's endemic disease control programs. In the recent past,interruption of these activities due to insufficient financing has led to ahuge setback in progress. Unsatisfactorl community resuonses to avoid risksof getting infected and to stop furtber spreading of endemic diseases havealso been a problem. In fact, large groups of people appear to maintainbehavioral patterns conducive to infection, despite warnings and fullknowledge of the risks implied in traditional habits or practices. ThMsadministrative frasmentation of SUCAM programs precludes an efficientoperation of disease control activities. Use of nesticides for vectorcontrol may raise concerns of environmental protection lobbies and constrainspraying against triatomineae, snails, and sand flies. Finally, lejalconstraints to hiring nersonnel in the public sector, as imposed by thedecree No. 91403 of 1985 and the law No. 7493 on elections norms, havehampered the development of effective endemic disease control programs inthe Northeast.

B. Country and Bank Goals, and Sector Leandina Stratety

1.18 Brazil's health development strategy may be summarized as follows:a) extension of basic health services, including family planning andzutritVon activities to target populations; b) strengthening of programs tocontrol endemic diseases; c) cost-containment and reduction of waste andfraud in INAhP8 services; and d) improvement of inter-agency coordinationand strengthening of the role of state and local governments in theadministration and delivery of health services.

1.19 Bank's health sector work in Brazil started more than a decadeago, with the inclusion of health components in Northeast rural developmentprojects. The Bank's first free-standing health project in Rondonia wasdesigned to improve access to basic health services, control malaria, andsupport applied research in tropical diseases, particularly malaria.Project implementation has experienced few difficulties, except for themalaria control component, which was overwhelmed by the tremendous increaseof malaria in the Amazon Basin. A special action program was set up lastyear to solve these problems, and a free-standing malaria control project isunder preparation. The second health project, approved by the Board in June1984, is supporting the development of a new model of Basic Health Servicesin the metropolitan area of Sao Paulo. A major purpose of the Sao PauloRealth Project is to demonstrate that a basic health services approach cansuccessfully address Brazilian urban health care needs in a cost-effectivemanner, leading to replication elsewhere in the country. An additional loanwas also approved in June 1984 to finance the National Health Policy Studiesto help the Government to better define medium-term sector policy andobjectives. A third health project, approved by the Board in May 1986, isintended to improve basic health services in the Northeast. Other projectswould be considered in the coming years: a project for controlling malariain the Northwest (see above), and a follow-up project on basic healthservices for completi.g the coverage of priority areas in all the Northeaststates.

II. THE PROJECT

A. Proiect Concept and Obiectives

2.01 Concent. This project is designed to assist the Government in afive year program to arrest the increasing trends of three endemic diseases(Chagas' disease, schistosomiasis, and leishmaniasis) in the Northeast, andreduce their prevalence to levels where they no longer constitute a publichealth problem. To achieve this goal, the project will: (i) control thepresence of disease vectors and intermediary hosts in the households andneighboring environments, by applying pesticides, and promoting healtheducation; (ii) rpduce the human reservoir of these diseases by earlydiagnosis and treatment of target population groups; and (iii) set upsurveillance activities for populations at risk.

2.02 Obiectives. The main objective is to reduce the prevalence ofChagas' disease, schistosomiasis and leishmaniasis and thbe intensity ofhuman infection to minimum levels where only epidemiological surveillanceactivities are needed to keep these diseases under control (see quantitativetargets in para 2.05). The main beneficiaries will be the school-agechildren and the agricultural labor force, whose health status andproductivity would be improved. A second objective will be to strengthenSUCAN's capacity and efficiency to expand the control activities in theNbrtheast. A complementary objective will be to support the NOR activitiesin reducing the occurrence of new AIDS cases.

B. Proiect Areas

2.03 The project will include about 1,018 municipalities infested byvectors in the nine Northeast states of Maranhio, Ceara, Rio Grande doNorte, Piaui, Paraiba, Pernambuco, Alagoas, 8ergipe, and Bahia; plussections of Minas Gerais (See Map IBRD 20434). The estimated population atrisk to be covered by the project is 30.0 million for schistosomiasis, and8.4 million for leishmaniasis. Laboratory facilities for Chagas' diseasecontrol wiil cover 12.2 million people living in chagasic areas of theNortheast and three other states outside the Northeast.

C. Hain Features

2.04 The project involves five components: three directlyaddressing the prevention and control of transmission of Chagas' disease,schistosomiasis and leishmaniasis; the fourth one addr'e3ing thestrengthening of logistical and managerial capabilities of SUCAM; and thefifth one, addressing the reduction of new AIDS cases.

2.05 Prevention and Control of Disease Transmission (PCDT).(US$170.5 million total cost): In a five year period, this component aimsat reducing: (i) the incidence of transfusional Chagas' disease by 80X; (ii)the prevalence of schistosomiasis to about 5S of present levels; and (iii)the incidence of visceral and cutaneous leishmaniasis by 70X and 501respectively.

2.06 Chagas' Disease: to control transfusional Chagas, the project willestablish a network of 12 Regional Laboratories, one of which will also be aCentral Reference Laboratory (CRL) in Minas Gerais, to test for Chagas'disease in blood donors and in cbagasic carriers (asymptomatic patients);and for serologic surveys of Chagas' disease for monitoring the humanreservoir in endemic areas. In addition, the project will complete theequipment of a reference laboratory for biological studies of Chagas'vectors, and will hire three clinical doctors for a pilot basic care programfor Cbagas' disease.

2.07 Schistosomiasis: to reduce the prevalence of this disease theproject activities will include: (i) applying molluscicides in selectiveareas to control snail reproduction; and (ii) performing stool tests inpopulation groups to diagnose and treat all positive cases; and performingstool surveys as part of program evaluation and surveillance activities.The project will also complete the equipment of a laboratory formalacological (snail) studies.

2.08 Leishmaniasis : to reduce the incidence of the visceral andcutaneous forms of this disease, the project activities will include: (i) anentomological survey in endemic areas and spraying of houses and neighboringplaces with DDT for controlling sand flies; (ii) household visits forserologic testing of dogs, and elimination of those found to be positive,and identification of suspected human cases for further diagnosis and

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treatment; and (iii) periodic screening of dogs and strengthening of thecase-reporting system. To achieve these activities the project will finance:

2.09 (a) The equipment of 22 regional serologic laboratories, (12 forChagas' disease and 10 for leishmaniasis); the expansion of aCentral Reference Laboratory (CRL) for quality control of labstandards, and training; and the equipment of 2 laboratories forvector research (for Chagas and for Schistosomiasis);

(b) hiring of about 385 higher-level staff and 2,820 other-levelstaff, and training of about 520 higher-level staff and 3,270other-level staff;

(c) acquiring about 65,250 kilograms of Niclosamide; 2.2 millionkilograms of DDT 75% concentrate and 123,000 kilograms of DDT 1001concentrate; 18 million capsules and 86 thousand bottles (240 c.c.each) of oxauniquine (praziquantel may be a substitute); and

(d) contracting of about 100 man-months of technical assistance.

2.10 The Government has provided assurances that required new vehicles(342 pick-ups, 4 trucks, 370 motorcycles, and 1,540 bicycles) included butnot costed in the project will be available.

2.11 AIDS Prevention and Control (US$9.3 million total cost). Theproject will support: (i) on-going activities in a multimedia AIDS educationcampaign targeted at high-risk groups as well as the population at large;(ii) a training program of health professionals in management, diagnostictechniques and epidemiology of AIDS; (iii) epidemiological studies in AIDSprevalence; and iv) the equipping of regional laboratories for blood testingand quality control of blood transfusions.

2.12 Community Nobilization (US$11.5 million total cost). The projectwill promote community participation in the control of vectors andprevention of disease by developing information, education and communication(IEC) activities including interpersonal communications with school childrenand other special groups, and massive community outreach by usingtelevision, radio, newspapers and printed material. For these activities,the project will finance:

(a) acquisition of furniture and equipment for 10 regional officesincluding audiovisual equipment and power generators for 22 pick-Ups;

(b) purchase of 23 videocassette sets; 23 overhead projectors; 14slide projectors; 14 photographic cameras; 10 electronic copiers;and 14 tape recorders;

(c) contracting the production, distribution and broadcasting of TVspots; radio jingles and spots; still fibls; and variablequantities of posters, calendars and flip charts;

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(d) hiring of 1 Information, Education, Commwnication (INC)specialist; hiring and training of 47 field workers;

(e) contract 20 man-months of INC technical assistance.

2.13 ODerational Research (US$ 1.5 million total cost).To solve practical problems in the disease control activities, the projectwill finance research dealing with the following subjects: (i) Biologicalcontrol; (ii) lab tests; (iii) vaccine testing; iii) epidemiological studiesto test the effectiveness of other interventions including behavioralchanges; and (iv) cost-effectiveness studies. The scope, relevance,duration, and applicability of research studies have been defined in anagreement satisfactory to the Bank between SUCAI and the Oswaldo CruzFoundation and signed on October 27, 1987.

2.14 Institutional Develogment (U8$25;2 million total cost).To improve SUCAM's field facilities, logistics and program management, theproject will:

(a) construct and equip 6 8UCAh's regional directorates and 19 local(district) offices; upgrade 11 SUCAM's regional and loc.slfacilities; remodel 15 spaces for serologic laboratories, and 2training centers; and furnish and equip 2 training centers and thepart of 8UCAM central offices related to project management;

(b) hire and train about 94 professionals and 38 technical level stafffor SUCAM headquarters and the 10 regional directorates;

(c) acquire 40 Lovibond kits (for toxicity tests), and develop 1seminar, 2 training courses, and one or more refresher seminars(in five years) on safe use of pesticides, for all SUCAM staff(Annex 2);

(d) contract 48 man-months for technical assistance.

D. Detailed Description

Prevention and Control of Disease Transmission (PCDT)

2.15 The strategy for prevention and control of these three endemicdiseases includes three well-defined phases: Prenaratorv Phase: consists ofa detailed mapping of infested areas including the plotting of each house;epidemiological assessment of vectors or intermediary hosts distribution;and cost estimates of inputs, i.e., pesticides, drugs, staff, etc., for afeasible operational plan. This phase has been completed during projectpreparation. Intervention Phase: consists of field operations including ISCactivities, applying pesticides for vector control, elimination of animalreservoirs, and mass screening and treatment of human cases. Igrveillanc-Phase: includes annual evaluation of disease prevalence and case finding ofvectors and new patients in the treated area (active surveillance), and

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compulsory reportiog of vectors and/or new cases (passive surveillance).Each reported new case will be subject to a full enquiry leading toidentifying sources of infection and immediate treatment. SUCAM willmonitor key performance indicators as a mechanism to improve operationsefficiency (Annex 4, Table 9).

2.16 Chamas Coutrol : Vector control (screening for infected triatominae,household spraying, entomological surveys) is currently financed byFINSOCIAL and patient treatment is handled by the state and INAMPS healthservices (para. 1.16). This project will finance only the surveillancephase consisting of blood testing for controlling transfusional cases ofChagas' disease (about 200 thousand blood tests), screening for cardiac andgastrointestinal complications in chagasic carriers (about 1 million bloodtests), and monitoring of disease prevalence in the endemic area (about 205thousand blood tests). Because the ELISA lab technique used for Chagasdiagnosis is also suitable for AIDS testing, and due to the growing problemin Brazil, this project will finance additional capacity for AIDS testing(see Annex 5). To achieve this, the project will:

(a) set up and equip a network of 12 regional serologic laboratorieswith a capacity for processing 50,000 blood samples per year,using WHO criteria for serum lab tests for Chagas' disease. Eachone of the 12 laboratories should function as a referencelaboratory at regional level; the one located in Belo Horizontewill serve also as a Central Reference Laboratory (CRL) and willreview 10X of negative tests and 1001 of positive tests, andmaintain other quality control standarts in the lab network. ThisCRL will also maintain quality control arrangements with theinternational lab network for tropical diseases sponsored byWMITDR. The physical space for the 12 labs and the CRL will beprovided by the State Health Secretariats (SE8), under agreementssatisfactory to the Bank (para. 2.39).

(b) establish a screening program for Chagas' disease in a populationsample of 30X of the children 7-9 years old, living in 2,000endemic municipalities. The total number of screening tests forChagas will be 200,000 a year;

(c) perform indirect immunofluorescence tests (IIF), indirecthemagglutination tests (IIA), and ELISA tests for Chagacdiagnosis; identification of risk factors and of cardiac andgastroenteric complications in about 1 million suspected chagasiccarriers. All reference laboratories will be equipped and staffedto perform these three lab tests;

(d) develop a training program including I seminar on the epidemiologyand control of Chagas' disease for cardiologists and 2 forregional doctors; 5 seminars for biochemists and 3 for technicianson the Chagas' disease control program and specifically on Chagas'disease lab tecbniques and quality control.

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2.17 Schistosomiasis Control: The project will maintain currentactivities in endemic areas under control with a population at risk of 14.2million, and will expand them to new endemic areas, mainly in the states ofBahia and Minas Gerais with a population at risk of about 15.7 million.

2.18 The intervention phase will consist of a stool test survey formass diagnosis in the populatiou at risk, using the quantitative Kato-Katzstool test. When 602 or more of positive tests are found in a locality, amass treatment of the population over 1 year of age will be made, using asingle dose of oxamniquine of 15.0 mg/kg body weight for persons over 12years old, and 20 mg/kg body weight for children under that age. (Asubstitute could be praziquantel). When the number of positive cases isbetween 42 and less than 602, then mass treatment will be restricted to thepopulation between 5 and 25 years old, which is normally the group with thehighest parasite load. If the number of positive cases is below 42, thenthe treatment will be restricted exclusively to these positive cases. Theecology of focal areab with more than 4X prevalence will be studied todetermine the snail strain and the feasibility of applying molluscicide.

2.19 Two consecutive evaluative surveys using the quantitative Kato-Katz test will be made with a 6-moath interval, in localities selected atrandom, for monitoring prevalence. After each evaluative survey, a workshopwill be held with community representatives, field workers and qualifiedprofessionals for deciding on next steps in the strategy of disease control.

2.20 When the prevalence found is about 5% or less, the area will enterin the surveillance phase. Case-finding of infected snails and new humancases will be undertaken through selective field lab tests. Positive caseswill be treated and, if there is no improvement, the patient should bereferred to the basic health services of the state Secretariats of Healthfor special studies. It is expected that some focal areas will remainresistant to this strategy and therefore will be treated differently asrecommended by operational resear^h studies (para. 2.13).

2.21 It is estimated that about 14.7 million stool tests, 8.4 milliontreatments and 100 thousand applications of molluscicide will be completedin the five year period. Niclosamide will be applied only in well-identified snail-breeding sites with epidemiological importance formaintaining the schistosoma's life cycle. Sanitation workel, biologicalcontrol, and/or behavioral changes in the population at risk will besupported by research studies (para.2.13) and by the mobilization ofcommunities (para. 2.29).

2.22 A training program will be developed including (i) a 6-monthtraining for three biochemists and 10 technicians in malacology, and a 3-month course for three lab technicians; (ii) two 1-month seminars for fieldlaboratorists and one for field inspectors on lab techniques and quality

1. Sanitation works for endemic areas are being considered in a Bank-financed Rural Water Supply and Sanitation Program.

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control; and (iii) two-week in service training for 123 chief guards, 202lab auxiliaries and 953 extensiou agents, on field lab techniques andepidemiologic procedures.

2.23 Leishmaniasis Control: Control of the two types of leishmaniasis(muco-cutaneous and visceral) vill be approacbed differently. Given thedifficulty in controlling the vectors and reservoirs of the muco-cutaneousleishmaniasis, the control strategy for this form of the disease will berestricted to improving the reporting of human cases for appropriatetreatment under medical supervision; the monit-ring of prevalence patterns;selective entomological surveys; selective application of insecticides forvector control; and elimination of infected dogs (reservoirs).

2.24 In the case of visceral leishmaniasis (Kala-azar), a simplifiedentomological survey and a serological survey of dogs will be carried out inareas covered by the project on the basis of the occurrence of human cases.Based on these surveys, fiel4 activities will consist of household spraying,elimination of sero-positive dogs, domiciliary visits for patient referralfor treatment, and health education.

2.25 The surveillance phase will start in areas where the prevalence ofinfected dogs is 3% or less. Selective serological surveys for case-findiugof infected dogs and clinical detection of suspected human cases will becarried out by field workers and health practitioners. It is expected thatall districts included in the program will enter in surveillance at the endof the fourth year of field activities (Annex 4, Table 4).

2.26 To achieve this stage the project will undertake an estimated 20.6mullion household visits, and 141,000 school lectures; 7.5 million serologictests in dogs; classification of about 110,000 sand flies from 72,600suspected habitats; elimination of about 650,000 infected dogs; applicationof 2.4 million house sprayings with DDT; and treatment of 40,000 newpatients with Glucantime.

2.27 The training program for leishmaniasis control will include: (i)a two-month seminar on prevention and control activities for 17 doctors;(ii) a two-month seminar on lab tecbniques and quality control for fivebiochemists, and 11 entomology technicians; (iii) a two-week training coursefor 48 lab auxiliaries; (iv) in-service training of 1539 extension agents;and (v) re-training of 58 lab technicians on leishmaniasis lab techniques.

Couaunitv Mobilization (CM):

2.28 This component will be carried out simultaneously with thecomponent for prevention and control of disease transmission. The SUCAMexperience is that without an effective participation of the communitiesaffected by endemic disease, the success in controlling them is limited.The organization of community groups for participating in control activitieswill be under SUCAM field personnel trained locally in group organization,motivatior and communication. Emphasis will be placed on how to conductgroup meetings, use of audiovisual equipment and mass education.

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2.29 A plan of action in each community affected by an endemic diseasewill include: (a) a A survey (knowledge, attitudes, practices, on endemicdisease control), with quick but relevant socio-economic data; (b)mobilization of existing organizations and groups, (c) organization of newones when necessary, and (d) discussion of ways in which SUCAM and thesegroups can work together in eliminating vectors and reservoirs of endemicdiseases, and how to prevent the transmission of these diseases in thecommunities. Assurances were obtained that the KAP survey will be completedby July 31, 1988 (para. 6.01 a). Implementation of (safe and practical)innovative initiatives for vector control or disease prevention resultingfrom these discussions and requiring small investments, will be financed bythe project (Annex 3).

2.30 For promoting community involvement in the control of endemicdiseases, SUCAM will strengthen its INC capacity by: (i) furnishing andequipping with audiovisual materials the Health Education Section atheadquarters and at the regional directorates; (ii) contracting about 6 man-months of technical assistance for procuring the production and broadcastingof audiovisual materials, and 14 man-months for assisting in the initialoperations, supervis.,n, and evaluation; (iii) hiring 1 specialist in humanresource development for headquarters, and 21 middle level technicalofficers with experience in health education or mass communication for theregional directorates; and (iv) 22 field assistants/drivers during the firstyear of project implementation. The headquarters Health Education Sectionwill develop 10 seminars for training regional and field workers in groupmeeting techniques, use of audiovisual equipment and mass communication (seeAnnex 3). Procurement and broadcasting of a mass media educational AIDSprogram will be also financed (para 2.11).

Ooerational Research (OR)

2.31 To help in the solution of practical problems in controlling thethree diseases, the project will finance studies involving priority subjectsfor research as described in para. 2.13. The Oswaldo Cruz Institute(PIOCRUZ), a research center of excellence in the country, has entered intoan agreement with SUCAN for execution of this component. Assurances wereobtained durinf neQotiations that such agreement will be updated no laterthan December 31. 1988. on terms satisfactory to the Bank (nara. 6.01 b).

2.32 A project research committee consisting of a FIOCRUZ seniorresearcher, a SUCAM division director, and a specialist in tropical diseasesfrom a University will be jointly appointed by the SUCAM project manager andthe vice-president of FIOCRUZ. The committee members may change accordingto the subject of the research proposal to be examined.

2.33 The committee will use four criteria to evaluate the researchproposals: (i) relevance for the control operations of the project; (ii)scientific validity; iii) time span within the project timetable; and (iii)costs.

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Institutional Development Component (ID)

2.34 This component aims at strengthening SUCAM's managerialcapabilities to improve efficiency and logistical support for maintainingand expanding control activities in the Northeast.

2.35 Organizational Strenzthenina: The project would implement a planof technical assistance to improve SUCAM's central, regional and localorganization and management; work environment; staff capabilities; andoperations efficiency:

(a) about 26 man-months of consultant services for improvingplanning, organization, and management processes and tools (e.g.,clearance procedures, document flow, administrative andoperational manuals, preparing an accounting system and setting upan accounting manual for the project);

(b) about 2 man-months for review and compilation of the sanitarylegislation;

(c) about 18 man-montbs for improving administration and logistics;

(d) about 2 man-months for improving efficiency of transportoperations;

Ce) about 2 workshops in training of trainers and 2 seminars forimproving staff motivation and "conflict management", and forpromoting the exchange of successful experiences among the states.

The objectives of the proposed technical assistance are described in detailin paras. 4.11-4.16. Terms of reference for five of the above consultantshave been prepared, and the remainder are in the process of being prepared.

2.36 Euman Resources Develoyment: SUCAM is understaffed and requires{i) improvements in personnel administration including job descriptions,staff selection, training and recruitment procedures; (ii) reoiganization oftraining programs, improvement of manuals and training of trainers; (iii)hiring by SUCAN through PAEO of 17 new staff for project management of which9 will be professionals and 8 clerical staff; employment by SUCAM of 100 newstaff to strengthen the administration of 10 regional directorates, of which'70 will be high level staff, and 30 will be secretarial staff; and 24 newdoctors seconded to the 8B8 to ensure the take-over of the screening andsurveillance activities by the 10 818 in the last year of projectimplementation. This comuitment will be included as part of the agreementsbetween the 10 U88 and SUCAM (para. 2.39). PAWO has entered into anagreement with SUCAM for hiring of consultants and key management staff.Assurances were obtained durint negotiations that such agreemet will beundated no later than December 31. 1988. on terms satisfactory to the BankCpara. 6.01 c) The development of human resources also includes about 40training courses for professional and technical staff which are describedfor each disease control program (paras 2.16-d; 2.22; 2.27), and a training

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plan for the AIDS program (Annex 5). Assurances were obt med durinanetotiations that the MOB will provide salary adiustments for the oproiectprofessional staff, within the limits of the Brazilian law. and that laborcosts will be financed by the Bank on a declining basis. As described inDara 3.15 (para. 6.01 d),

2.37 Administrative facilities: In the Northeast and Minas Gerais,SUCAM operates 10 regional administrative directorates in the state capitalsand about 40 local (district) offices, most of them in rented buildingsunsuited for administrative, technical, and logistical functions. As partof SUCAM's strengthening, the project will construct, equip, and furnish theadministTative buildings for 6 regional directorates and 19 local offices;and will upgrade 11 regional and local facilities. Regional directorateshave an average size of 4,500 m2 and include administrative offices; smalllaboratories; library; warehouses; pesticide otock rooms; and mechanicalworkshops (localization of these facilities are in Annez 4, Table 7). Also,the project will complete the equipment of two training centers located inRecife and Feira de Santana.

2.38 Before negotiations, SUCAM bad forwarded to the Bank draftagreements acceptable to the Bank (a) between SUCAN and FIOCRUZ forexecuting the project research component; (b) between SUCAM and PARO forhiring consultants and key management staff; and (c) between SUCAX and theState Secretariats of Health (888) for the provision of lab space and forimplementing medical care and surveillance activities of the project.

2.39 A condition of effectiveness is that the borrower shall haveentered into agreements with either (i) the SS of states coverins 5OX ofthe agaresate area of all narticivating states: (ii) the $ES of vrojectstates with an ainregate population not le than 16 million: or (iii) thLSBS of anv five groiect states. Given the estimated population at risk(approximately 30 million), the number of participating states and the factthat at least one of the three diseases covered within the project isprevalent in any given part of a project state, satisfaction of any one ofthese conditions necessarily ties project effectiveness to acceptance in atleast balf of the project states, area, population and/or number.

III. PROJECT COSTS AiD FINANCING

A. Proiect Costs

3.01 Summary of Proiect Costs. The total cost in terms of the projectexcluding taxes of US$9.4 million, aud including US$10.0 million of physicalcontingencies and US$6.3 million of price contingencies, is estimated to beUS$218.0 million equivalent, of wbich US$89.4 milliou will be foreignexchange. The distribution of local and foreign costs by component issummarized in page iv of the Loan and Project Sumary, and a summary ofcosts by project component, by year and by category of expenditures is givenin Annex 6.

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3.02 Cost Estimates. Estimated construction costs for the project arebased on unit prices derived from current contracts and cost analysis forsimilar standards of construc'. on in corresponding facilities, withadjustments of 51 to 101 for regional cost differences. Estimated costs ofequipment, furniture and vebieles are based on current c.i.f. unit prices,adjusted to iuclude local transportation costs and, where appropriate,installation costs. Estimated costs of consultant services a&W training,which draw on recent experience, are based on current WHO/PAHO pay-scales.Project cost estimates do not include any identifiable import duties ortaxes. Baseline costs in US$ were estimated at pre-appraisal (March, 1987)when the official US$ rate was Cz$17.9 per US$. After that date, anychanges in number or price of project inputs, will be introduced directly inUS$ using the current exchange rate.

3.03 Coutiaencv Allowance. The project cost includes physicalcontingencies equal to 10 of the estimated costs of civil works, and 52 ofthe estimated costs of other categories of expenditures. The project costalso includes price escalation contingencies calculated for the five-yearperiod beginning January 1988. The following estimated annual rates ofinternational price increases are used in the calculation of pricecontingencies: 1X for the period 1988-90 and 3.51 for the period thereafter;this is in accordance with Bank guidelines. As it is difficult todifferentiate between price trends for manufactured goods, civil works andtechnical assistance, the above estimates are applicable to expected priceescalation of all expenditures. The above estimated rates have been appliedto local and foreign costs as well, as periodic currency rate adjustmentsbased upon purchasing power parity would compensate the differences betweenprojected US$ inflation and local inflation rates. Prices are expected toincrease during the project implementation period by a total of about 3.11of the total baseline cost, plus physical contingencies. Totalcontingencies are estimated to be about 81 of the baseiiine cost.

3.04 Foreian Ex-hanae Comuoneat. The foreign exchange component isUS$89.4 million equivalent or about 411 of the total project cost. Thecalculation of the foreign exchange component is based on the expectationthat: (a) all civil works will be contracted to local firms, (b) most of thespecial lab equipment and drugs will be directly imported, (c) otherequipment, furniture, and reagents will be supplied by local manufacturers.

B. Proiect Financing Plan

3.05 The proposed loan of U8$109.0 million equivalent will finance 1002 ofthe total estimated foreign excbange cost and 151 of the local cost of theproject. The loan will be for 15 years, including a three-year graceperiod. The Bank loan will be made to the Federative Republic of Brazil,which will carry the foreign excbange risk and provide counterpart funds asnecessary to complete the project.

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FINANCING PLAN a/

Local Foreign Total-- (US$ million)-----

Federal Government 109.0 - 109.0IBRD 19.5 89.5 109.0

Total 128.5 89.5 218.0

a/ Includes physical and price contingencies. Excludes taxes.

3.06 Recurrent Costs. The annual iucremental recurrent costs of theproject would be about US2.8 million during the first year of operation.US$2.25 million during the second year and US$2.22 million in the subsequentyr=rs, which would respectirily represent 3.62, 3% and 2.9% of SUCAM'sprojected recurrent expendit. as in 1988. In view of the high prioritygiven to this project. SUCAM can be expected to meet these additionalexpenditures.

C. PROCUREMENT

3-.07 Procurement under the Bank Loan is summarized in Table 3.1.

3.08 As the cost of the largest civil works is relatively small(about US$1.0 million average for the new directorates) and construction isdispersed over a large number of cities and small towns in the Northeast ofBrasil. it is unlikely that their construction will attract foreign bidders.

Table 3.1: PROCUREMENT BY CATEGORY OF EXPENDITUREUS$ millions

I PROCUREMENT EtODI 'CATEGORY -I ICB LCB Other I/A TOTAL COST I1-- ------ I- -I Civil Works 13.0 2.0 15.0 II (6.5) (1.0) (7.5) 1

I Equipment & furniture 4.0 11.0 2.5 17.5 1I (4.0) (5.5) (1.25) (10.75) 1

I Chemicals & Drugs 11.5 10.0 19.5 a/ 41.0 1I (11.5) (5.0) (19.0) (35.5) 1I tI IEC (Mass Media) 7.5 1.0 8.5 11 (3.75) (0.5) (4.25) 1I II Training & Tech. Assist. 5.0 5.0 1I (2.5) (2.5) 1I .II Wages for Additional Other Staff b/ 31.0 60.0 91.0 11 (15.5) (16.5) (32.0) 1

I Research & Innovative Activities 2.0 2.0 1I . (1.0) (1.0) 1i II Incremental Operating Costs c/ 38.0 38.0 11 (15.5) (15.5) 1I TOTAL 15.5 41.5 63.0 98.0 218.0 11 (15.5) (20.75) (40.75) (32.0) (109.0) 1

Note: Figures in parentheses are amounts financed by the Bank.

a/ Includes $0.8 million for reagents and biologicals, $3.7 million forniclosamicle, and $15.0 million for oxamniquine.

b/ The term "Additional Other Staff' means Other staff hired afterDecember 31, 1987 by SUCAM or a State or a Municipality, as the casemay be, for the purposes of the Project and to be financed out of theproceeds of this loan.

c/ The term "Incremental Operating Costs" means (a) wages for Righer-levelstaff hired by SUCAN or a State, after December 31, 1987, to do fieldwork; (b) supervision expenses, including per diem and transport; andfuel and vehicle maintenance sxpenses, for all purposes of the Project.

Therefore, contracts for new construction (total WS$13.0 million, includingcontingencies) financed under the loan will be awarded according to localcompetitive bidding procedures, which will be acceptable to the Bank andwill not exclude foreign participation. All other civil constructioncomprising extension and refurbishing of existing facilities, estimated to

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cost in total US$2.0 million equivalent, will be carried out by forceaccount in each Regional Directorate, through agreements between SUCAM andthe local Department of Public Works in each municipality, which will bereviewed and approved by the Bank prior to their signing.

3.09 Equipment and furniture amounting to US$17.5 million equivalent,including contingencies, vill be grouped, to the extent possible, in largepackages to permit bulk procurement. Contracts for equipment and furniturein excess of US$250,000 will be awarded on the basis of ICB procedures inaccordance with the Bank Guidelines of May 1985. Small items or groups ofitems estimated to coo.t less than US$250,000 equivalent, or specializeditems for which ICB is not practical, will be purchased through LCBprocedures which would be acceptable to the Bank. These items will notexceed an aggregate total of Us$11.0 million, or 151 of the total estimatedcost of goods and works, including contingencies. Readily available off-the-shelf goods or standard specification commodities of not more thanUS$25,000 in value could be procured through prudent shopping on the basisof prices quoted by at least three local suppliers. Item so procured willnot exceed a total of US$3.5 million, or 41 of the total estimated cost ofgoods and works, consisting of US$2.5 million of equipment and furniture andUS$0.8 for reagents and biologicals. Niclosamide (about U8$4.0 million) andoxamniquine (US$15.0 million) have a single source of procurement, andtberefore will be contracted directly from the sole manufacturer. Brazilianlegislation has prohibited imports of vehicles and computer bardware;therefore these "reserved procurement" items were excluded from projectcosts and from Bank disbursements. Durina negotiations, assurances wereobtained that the i)rocurement 2rocedures will be carried out as describedhere and accordins to the Guidelines on Procurement under I8RD Loans and IDACredits of May 1985 (para. 6.01 e).

3.10 The selection and appointment of consultants for studies andtechnical assistance will be in accordance with the August 1981 "BankGuidelines for the Use of Consultants by World Bank Borrowers and by theWorld Bank as Executing Agency." Incremental operating costs includeUS$38.0 million for incremental staff salaries, vehicle maintenance andfuel, for which procurement is inapplicable.

3.11 For the purpose of comparing foreign and local bids under ICB,domestic manufacturers will be allowed a margin of preference equal to theexisting rate of custom duty applicable to competing imports or 151 ofc.i.f. price, whichever is lower.

3.12 The Bank will review and approve before contract award, all draftbid documents and contracts for goods to be procured through ICB and thefirst five contracts for procurement of goods under LCB. Prior Bank reviewof procurement documentation and contract award recommendation will berequired for all new civil works construction contracts above the US$0.5million equivalent. Prior Bank review of procurement docusentation willcover 761 of total amount of goods and works financed by the Bank.

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D. Disbursements

3.13 Health projects in Brazil have a good record of disbursements (theRondonia Health project is about to be completed in six years. and the SaoPaulo Heilth project, with two and a half years of implementation isexpected to be completed as scheduled in four years). Because of SUCAM'sgood record as an institution, its field experience. and the "campaign"nature of the project, no major delays in disbursements are anticipated.The disbursement schedule has therefore been maintained at five years.similar to the project's timetable. The project Completion Date will beJune 30. 1993. and the Project Closing Date will be December 31. 1993.

3.14 The proceeds of the IBRD loan (Table 1, Annex 7) will be disbursedas follows:

- 50X for civil works, including architectural fees;

- 100l of foreign expenditures and 50% of local expenditures forequipment and furniture;

- 1001 of foreign expenditures and 501 of local expenditures forcherical supplies and drugs;

- 50X for IEC (mass media) activities;

- 1002 of foreign expenditures for consultant services hired abroadand 502 of local expenditures for training; local technicalassistance; research; and innovative activities;

- 35% of total expenditures for labor costs in a declining basis,starting from 60% down to 25% as described in para 3.15.

- 41X of eligible operating costs.

No disbursements will be made against vehicles or computers.

3.15 Disbursements for local expenditures above US$200.000 equivalentwill be made after receipt of full documentation. except in the case ofcivil works by force account; disbursements for goods and services providedunder contracts valued at US$200,000 equivalent or less for local currencyexpenditures and US$50,000 equivalent or less for foreign expenditures willbe made against certified statements of expenditure (SON). The SOB will becertified by the project implementing agency incurring the expenditure andby the Department of Financial Administration (DAEI) in SUCAM headquartersin Brasilia. in its capacity of Project Financial Administrator. Supportingdocumentation will be retained by each implementing agency and DAFI, andmade available for inspection during Bank supervision missions and byexternal suditors. Labor costs, including wages and supervision will befinanced in a declining scale starting at 602 up to an aggregate of US$5.0million- thereafter 50% up to a total disbursement aggregate of US$11.0million; thereafter 402 until a total disbursement aggregate of US$17.0

- 22 -

million; thereafter 302 up to a total disbursement aggregate of UB$ 22.5million and 25X thereafter.

E. Accounts and Audits

3.16 To facilitate Bank disbursements, two Special Accounts will beopened. Funds could be moved from one to the other with Bank authorizationexcept that the Bank may make that transfer unilaterally at any time witbina period ending six months after the date of the Loan Agreement. (i)Cruzado Expenditures Special Account (CEIA) will be opened in US dollars inthe Central Bank, with an initial deposit of up to US$8.0 million, withdrawnfrom the loan account. Withdrawals from the CESA will be supported by 80E'sor required documentation as specified in para. 3.15, and payments will bemade at the Cruzado exchange rate that prevailed on the date ofexpenditures, provided that the expenditures have been made within 90 daysbefore withdrawal is made from CUBA. Otherwise, the rate of exchangeapplied shall be the one prevailing at the date of the withdrawal from CUBA.(ii) To facilitate disbWirsements for foreign contracts and training abroad,a Foreign Exchange Special Account (FE8A) will be established with loanfunds in dollars in a commercial bank abroad with an initial deposit ofUS$0.5 million, which would be operated by SUCAM. Disbursement requests forthe replenishmeut of CESA and FESA will be submitted at agreed intervals.

3.17 The MOH's Secretariat of Budgeting and Finance Programming (SOPF)will be in charge of allocating the project funds to SUCAM's sub-account.SUCAM will channel project funds through its sub-account, from headquartersto the respective Regional Directorates using a Banker's order. Projectfunds will be managed by SUCAM's DAFI and will be clearly identifiablewithin SUCAM's account to allow annual audits by independent auditorsacceptable to the Bank and according to procedures satisfactory to the Bank.The Special Account at the Central Bank will also be audited by independentauditors satisfactory to the Bank. Copies of SUCAN's and Central Bank'saudited statements will be sent to the Bank within six months of the end ofeach fiscal year. The auditor's report will include an opinion andcomments, as necessary, on the methods employed in compiling the statementof expenditures, their accuracy, the relevance of supporting documents,their eligibility for financing in terms of the project's legal agreement,and the standard of record-keeping and internal controls related to theforegoing.

IV. PROJECT ORGANIZATION AND IMPLEMENTATION

Proiect Ornanization and Manatement

4.01 SUCAN will be responsible for overall project coordination andcontrol. SUCAM is a federal agency within the organizational structure ofthe Ministry of Health (MOR) (see Chart 1, Annex 8) and therefore subject tothe legislation governing the administration of the public sector. Itsdirector, called Superintendent, is proposed by the Minister of Realth and

- 23 -

appointed by the country's president. SUCAM is represented in eacb one ofthe 26 states by a regional director whose appointment is proposed by theSuperintendent and made by the Minister of Health.

4.02 Project Orzanization: The project will be located in theCoordination Unit of Projects Management (COGEP). This unit was created bythe Portaria Ministerial No. 421 of August 27, 1987, and will dependdirectly on the Superintendent (See Chart 2, Annex 8). This newCoordination Unit satisfies the need for strong organizational positioningof this project. COGEP will be hierarchically located at the same level asthe other departments (DECEN, Finance, Personnel, Administration) to benefitfrom: (i) a direct reporting relationship to the Superintendent; and (ii)the ability to draw on the expertise of the other departments. Thedepartment's director will be appointed by, and report to, theSuperintendent and will be the project manager.

4.03 COGEP will be advised by a Technical Advisory Committee (TAC),created for the purposes of monitoring the coordination of the projectcomponents and evaluating the performance of the project's objectives. TheTAC is made up of the Superintendent, Department Directors, and the DivisionChiefs of the three endemic diseases included in the project, and will eeton a quarterly basis to review the quarterly progress report prepared byCOGEP, and to provide advice on project implementation.

4.04 The SUCAM's Regional Director in each of the ten RegionalDirectorates will be the project regional coordinator. Re will report tothe project manager on project matters and functionally to theSuperintendent.

4.05 Proiect Management. At the federal level, the Superintendent ofSUCAM will be responsible for the execution of the project in accordancewith the project description contained in this report and conditions agreedon and reflected in the Loan Agreement. He will delegate the authority tomanage the project to COGEP whose manager in turn will delegate parts of hisauthority to the SUCAM regional coordinators at the state level.

4.06 Project objectives have been formulated and quantified during theproject preparation process. Strategies on how to achieve the statedobjectives have also been decided and would be subject to periodic reviewsbased on results obtained. Within this context the Project Manager willcarry out the following activities:

(a) Programing: with the assistance of COPLAN, decide on a yearlybasis how programs and subprograms will be implemented and theamount and type of resources to be devoted to each program, andthe ways in which these resources will be used;

(b) Budgeting: with the assistance of COPLAX, the programs will betranslated into monetary terms covering specified periods of time,and budgets will be assigned to the regional directors who arecharged with executing the programs;

- 24 -

(c) Operating and Accounting: through DAFI records will be kept ofresources consumed and outputs achieved during the period ofactual operations. The records of resources consumed (costs) willbe structured so that costs are collected by programs. and therecordo of outputo achieved will be the basis for monitoring andevaluating the project's performance;

(d) Reporting and Analysis: reports will compare planned outputs andinputs with actual outputs and inputs. Reports will be shared foranalysis on a regular basis with the Superintendent. TAC, MOH, andfor each state with the Regional Directors and Coordinators.

4.07 The Project Manager will be responsible for maintaining goodworking relations with inter- and intrasector entities and organizationswhich are directly or indirectly involved in the successful execution of theproject. e.g.. with the Ministries of Planning and Treasury for the flow ofexternal funds and project audits, with FIOCRUZ for the research program.with State Health Secretariats for the coordination of case finding andreporting, case treatment and follow up. A Project Manager acceptable tothe Bank has been appointed. Assurances were obtained at negotiations thatthe Bank will have an opportunity to coment on the qulications andexperience of any ubsequentproject manaer (para. 6.01 f).

4.08 At the state Level, responsibility for implementing the projectwill rest with each of the ten SUCAM regional directorates. The regionaldirector will be the project coordinator and will be responsible forprogramming the state project actions and expressing them in a state budget.supervising the operations and keeping records of resources consumed andoutputs achieved, and reporting planned and actual inputs and outputs.Together with his regional and district staff. the project coordinator willanalyze the results on a regular basis and propose program changes to theProject Manager, if warranted.

4.09 Incremental Management Staff. Timely project execution willrequire strengthening the management of SUCAM in general and of the projectin particular through adding and training staff in specific functionalmanagement areas at three levels: the central level, the regionaldirectorate level, and the state health secretariat level. A total of 141staff positions will be added of which 103 are classified as higher levelpositions and 38 as middle level or clerical positions. The central level(COGEP) will only be allocated 14X of the incremental staff and the largemajority (662) will be assigned to the regional directorates. To strengthenthe coordination and integration of program ezecution, the state healthsecretariats will be provided witb resources to hire 24 physicians or 23S ofthe higher level incremental staff.

4.10 Five functional management areas will be strengthened at thecentral and regional directorate levels: personnel, materials managementand transport, budgeting and accounting, field operations, and socialmarketing. The central level (COGEP) will also be staffed with a project

- 25 -

manager, two assistant project coordinators, oue research coordinator, onecivil works coordinator, and one technical assistance coordinator.

Institutional Strengtheninz of SUCAM

4.11 The project will finance technical assistance to prepare thereorganization of SUCAM and to assist in its implementation. 8UCAM isbarely 15 years old and has grown rapidly to about 30,000 people, of which22,600 work in field operations. This quick growth has strained itsoutmoded structure and the original management systems and processes. Timehas come to take a comprehensive look at SUCAM's structure and managementand to adapt it to today's and tomorrow's needs. The project will provideabout 48 person-months of technical assistance in the following interrelatedareas: organizational design and general management, planning systems,human resources development, logistics, transport, and supportinglegislation. Each functional area will work in close cooperation withSUCAM's management information system which is being developed concurrentlyand which would serve the needs of these areas.

4.12 Orgatization and Management of SUCA! (18 person-months): topropose mid-ternm and song-term alternatives to the present organizationalstructure and management of SUCAM in order to make it a more efficient andeffective organization. Consideration will also be given to, igtel alia.municipalization of SUCAM services and integration of some or all of itsservices with the State Realth Secretariats. The intended outcome will be a5- to 10-year forward plan with staged phases and an analysis of thefinaucial and legal implications. The initial implementation phase willstart in the third year of the project.

4.13 Plannina Systems (8 person-months): to develop a planning,budgeting and control model, including developing a project accountingsystem, which will allow central and regional management to plan and controlSUCAM's performance on a regular basis. The anticipated outcome would be adiagnosis of the current situation, a proposal for a comprehensive planningsystem at the central level and the regional level, and a time-specificimplementation plan.

4.14 Administration and Logistics (18 person-months): to define anddevelop (i) types of training most appropriate to SUCAM' s evolving needs,course contents, and teaching methodology and materials; (ii) alternativerecruitment mechanisms, such as, hiring staff through municipalities and/orstate health secretariats, contracting for services with private sectorfirms; (iii) to improve management procedures and processes for timelydelivery of tools and ssipplies in sufficient quantities to the field staff;encouraging of the incipient decentralization process to the levels ofdistricts and subdistricts, and for reducing and streamlining the number ofauthorizations and request forms.

4.15 Transuort (2 person-months): to make an inventory and a disgnosisof SUCAM's transportation fleet and its problems, to propose alternativeorganizational and legal arrangements for maintaining and repairing the

- 26 -

vehicles, such as, standardization of makes, contracting ror services withmunicipalities, state governments or the private sector.

4.16 Letislation (2 person-months): Legislation dealing with endemicdiseases has evolved piecemeal over a number of decades. This consultancywill review all existing legislation and will compile in a single documentto serve today's legal needs of SUCAN.

4.17 SUCAM had coutracted by the time of negotiations, at least tvo ofthe consultants described in paragraphs 4.14 and 4.15, according to the nXkGuidelines for the Use of Consultants of August 1981.

Status of Proiect Preparation

4.18 StICAM and the regional directorates already have capable managersand key staff to initiate project implementation. The Government has givenhigh priority to this project, and SUCAN has appointed a team to completeproject preparation (Resolution NO. 1024, 12/12/86). The preliminarydrawings for new administrative facilities have been completed and foundsatisfactory to the Bank. About 19 of 24 sites have been selected andacquisition of land is under way. A procurement plan for LCB and ICB isunder preparation by the SUCAM's financial department. Terms of referencefor hiring consultants in logistics, and management have been prepared, andcontracting mechanisms through PAHO are in place, according to Bank's"Guidelines for the Use of Consultants by World Bank Borrowers and by theWorld Bank as Executing Agency (August 1981)." At pre-appraisal, it wasagreed that all these initiating activities will be considered forretroactive financing up to an amount of US$1.5 million. The project designand costs estimates have been compieted. Project field activities willstart in at least three regional directorates by July 1988.

V. PROJECT BENBFITS AND RISKS

A. Health and Environmental Imnact

5.01 Health Impact: Three major benefits for about 30 millionNortheast poor peasants, small farmers and urban dwellers are expected to bederived from this project: first, a substantial reduction of the risks ofacquiring Chagas' disease, schistosomiasis, and leishmaniasis. An externaleffect will be the reduction of rabies and malaria due to elimination ofdogs and DDT spraying for controlling leishmaniasis; second, a substantialreduction of morbidity and disability due to those diseases is expected; andthird, savings on medical and hospital care costs and gains in productivityof the labor force will also be important.

5.02 A fourth benefit will be the increase of SUCAI's efficiency due tothe strengthening and improvement c! management, administration andlogistical operations. The institution-building effect of the project willbe at least as important as the direct health benefits since it will have a

- 27 -

spill over effect in the efficiency of controlling other diseases such asyellow fever, malaria, bubonic pest, and trachoma.

5.03 Bnvironmental impact: Although the project will use twopesticides, namely DDT end Niclosamide, no negative environmental impact isforeseen since the amounts to be used are minimal in comparison with thoseused in agricultural projects. and the areas to be sprayed witb thosepesticides are small. Usage of DDT as a residual indoor insecticide causesno environmental contamination and does not constitute a health risk.Niclosamide will only be used in sites carefully selected as to avoid risksof water contamination. Furthermore, the project includes continuoustraining activities on safe spraying techniques and surveillance ofpesticide use and manipulation. The OPN 11.04 on "Guidelines for theSelection and Use of Pesticides in Public Health Prog_ams in Bank FinancedProjects" have been followed in the preparation of this project.

S. Project Risks

5.04 In the past, SUCAM has had difficulty recruiting and retainingstaff because of: (i) low salaries as a federal agency; and (ii) the barshand at times dangerous working conditions in the field. During projectpreparation strategies to insure the employment of all field staff requiredfor successful control of the three diseases in question were discussed.These included (i) the possibility of contracting out specific tasks to theprivate sector; (ii) the hiring by municipalities. which are not subject tofederal salary scales and whicb can pay higher per diems and hardshipallowances. of field staff; and (iii) the hir5ng of some staff by the statehealth secretariats. which are also not sub$- . to federal salary scales(states already recruit 172 of tbe higher level incremental staff Epara.2.361). SUCAM plans to use all these strategies. With respect toamunicipal hiring, the project preparation staff has classified the 1.018municipalities included in the project into three categories according toadministrative capacity to recruit personnel. SUCAM estimates that by theend of the first semester of project activities, about 650 contracts wouldbe signed between SUCAM and those municipalities with good administrativecapacity (Category I); and of the 390 municipalities with weakadministrative capacity (Category II) two thirds (260) will be providedteehnical assistance to hire field staff. SUCAM will hire directly for thethird category of municipalities. This strategy will be in line with thecountry's municipalization policy.

5.05 Moreover, at negotiations assurance was obtained that, ifnecessary, the Govermet will arrange for contract staff to be hired bystates and municipalities (allowin for payment of better wages, higher perdiems for field work and hardship allowances), with reimbursement by SUCAMto states and municipalities from Loan proceeds (para. 6.01 g).

- 28 -

VI. RECOMMENDATIONS

6.01 Assurances were obtained during negotiations that:

(a) The KAP survey including socio-economic data will be completed byJuly 31. 1988 (para 2.29);

(b) terms of the agreement between SUCAM and FIOCRUZ for execution ofthe operational research component of the project will be updatedno later that December 31, 1988. on terms satisfactory to the Bank(para. 2.31);

(c) terms of the agreement between SUCAM and PAHO for hiring ofconsultants and key management staff will be updated no later thatDecember 31. 1988. on terms satisfactory to the Bank (para. 2.36);

(d) the MOH will provide salary adjustments for the projectprofessional staff, within the limits of the Brazilian law, andthat labor costs will be financed by the Bank on a decliningbasis, as described in para 3.15. (para 2.36);

(e) the procurement procedures will be carried out as described hereand according to the Guidelines on Procurement under IBRD Loansand IDA Credits of May 1985 (para 3.09);

(f) the Bank will have an opportunity to comment on the qualificationsand experience of any subsequent project manager (para. 4.07).

(g) strategies to support the hiring of workers by municipalities andstates will be implemented (para. 5.05).

6.02 The following is a condition of effectiveness:

(a) the borrower shall have entered into agreements with either (i)the SES of states covering 50% of the aggregate area of allparticipating states; (ii) the SBS of project states with anaggregate population not less than 16 million; or (iii) the S3 ofany five project states (para. 2.39).

6.04 With the above conditions and assurances, the project is suitablefor a Bank loan of US$109.0 million to the Ministry of Health of theFederative Republic of Brazil. to be repaid over a period of 15 years.including three years of grace.

29- A4M I

BRAZILPORTNIAST INDIVIC DISIABi CONTROL PROJECT

CIAGAS' DISEASIESTINATED PRIVALINCB Al STATS: IRAZIL (1976-81)

STATS I POPULATION IIZPSCTSD M0. Otl BST?XATID II IPOSITIVt CASES I PREVALSOC3 I

- MINAS GERAI1 S 5869855 1 518326 1 8.8SI- 10 GRAND2 DO SUL I 2913025 1 257441 1 8.8SICOIAS 1786663 1 132204 1 7.421

- 531013P 1 459692 1 27441 1 6.031-BAIA I 4930925 I 268179 I 5.4S1

- PIAUI I 956623 1 3870S I 4.0S1- PARANA I 4164943 1 166511 1 4.021- PARAISBA I 1405793 1 48863 1 3.5ZI- P?RNANIUCO I 2583119 1 72053 1 2.82S- NATO 01080 618910 1 17480 1 2.821- ALAGOAS I 1012240 1 25058 I 2.521- NATO BOS80 o0 SUL I 457896 1 11265 1 2.5SI- ACRE I 143081 1 3422 1 2.421- AMAZONAS 435379 1 8195 I 1.921- RIO GRAND! DO NORTEI 883765 I 15713.1 1.821- RIO DE JANEIRO I 1519673 1 26657 I 1.8SI- SANTA CATARINA 1 1937461 1 26936 1 1.421- ClA&A I 2855591 1 24018 1 0.821- AU 1 1166978 1 6532 1 0.621- RONDONIA I 171750 I 710 1 0.421- RORAIM 1 32285 I 100 1 0.321- ESPIaITO SANTO I 832804 1 2629 1 0.321- KASANRAO I 3157419 I 3902 1 0.12,- AMAPA I 56357 1 0 1 0.021

BRAZIL: TOTAL I 40352227 1 1702340 1 4.2ZIueesuus.eiuee.ue.u.eine.weusmee"=waeuuae.ene.ew.*"@@**Z **einae.u*u

- 30 -AN=E

BRAZILNORThEST ENDEMIC DISEASE CONTROL PROJECT

CEAGAS' DIS2ASEPROcAUM COVYEAGE ST AREA AND POPULATION (1986)

I PROGRAM COVERAGE I UNDER SURVEILLANCE IREGIONAL I

DIRECTORY I 0 OP I AR&A IPOPULATIONI NO. OF I ARIA IPOPULATIONII #UNIC2PIOS 1 (i)2) 1 1 MUNICIPtOS I (ZM2) 1 1

- ALAGOAS I 95 1 27633 1 1752024.1 18 1 3506 1 315565 I- SANIA I 319 1 486261 1 10331151 1 39 1 41001 1 944509 1- DISTRITO I 1 1 5771 1 1742826 1 1 5814 1 1741434 1

PEDERAL I I I I I I- GOIAl S 244 1 708222 1 4540635 1 77 I 381076 1 1137984 1-ARANO I 107 1 228281 1 4092575 1 23 1 92772 1 970772 1

- MATO GROSSO 1 64 1 371146 1 1723165 1 19 1 103969 1 394279 1DO SUL I II I I I I

- MtAS GERAIS 498 1 509727 1 11726698 I 72 1 24401 1 3933775 1- PARtIA I 145 1 49802 1 2061446 1 4 1 336 1 26168 1- PAANA I 203 1 108245 1 4109808 1 99 1 6567 1 420132 1- PEtNAMUCO I 163 1 90249 1 4319541 1 34 1 9136 1 1012034 1- RiO GRANDE I 136 1 202614 1 4093942 1 20 1 39698 1 908929 1

D0 SUL I I I I I I- StRPE I 75 1 15687 1 1291616 1 8 1 2057 I 379912 1

- RZIL: TOTALI 2050 12803638 1 51785507 1 414 1 710334 1 12185483 1

'AM=~ 1Table~ 3-

* Fl^~~~~~~RZILNORThEAST ENDEMIC DISEASE CONTROL PROJECT

8CUIITOSOMIASISTRENDS 0 PEOPLE TESTED, POSITIVE CASES, AND CASES TREATED

IN SELECTED LOCALtTIES OF TEE NORTTIAST(1977-1905)

YEZ A Rft-ft ------- -

TRENDS 1 1977 1 1980 1 1983 1 1985 1

N0. OF PEOPLEI 418284 1 1684619 1 2091407 1 2630653 1TESTED I I I I I

I I I .*I IO Of POSITIVEI 24.5S1 9.821 8.821 7.821CASES I I I II

I I I I INo. 0 CASES 1 .294130 1 1296703 1 811100 1 700900 1TREATED I II

SCAI l I C I

-Sonise: SUCAM/DIESCE

-31- T-bl 1Table 4

NOtItUEAST E0SNIC 81I8tAS COMT3OL lIOJIC?

S¢2t81080tt^8ISUINENIC AMIA, POPULATION Al 328 AID 3l13301 Ps2CI3

is 0os1T3A1T W3*1, (1967)

aa.amflaaa ....... a .fta--- as ... ....aaa.aaaaaaaaaean

1201O0AL I Alt I 30. 0o I OPOSILAUOt IUSTISATIO W0. 01PIIICIOLS I (132) In LOCALITSI I (XS1. '$S) I slhtDWO" ILUCISIaaflaaaflfl Oafta-aa ----aaa.aaa a .... f-------aa

- NASOAOUA I 71651 1 4373 I IG10010 I 1311 5PIAUI I 4)4 1 3)0 I 21554 I 249 1

- CtAR 5 24200 1 3603 1 2332557 1141 1- 3*0 GullsA 9265 1 1325 1 926060 1 45S 5

sO OSI I I I I I- PARAIBA 5 9956 I 31505I 1054200 1 945 I- PE3uAN3DCO I 17000 I 5619 1 3269022 1 1745 I- ALACOAJ I 16704 1 0210 1 1819299 1 16U3 1- 5102t13 I 11334 1 4426 1 947045 1 1327 1- "AUZ 5 381230 1 0)377 1 10941508 1 16740 1- NIM Glu3s I 211007 I 51100 I 9007232 1 15348 1

A 34 ?Al3 tOTALI 956S92 1 144016 1 32210462 1 4)127 1

ANNEX 1Table 5

534221P3Ot31346 ENDENIC 0t163Jt CONTlOL PROJICT

tIPOIStD CAStS 0 CUTANEOUS 4At VSCERAL LZISINAANIASItg 8OSTNAStAN$ SAlTES 1SETVE 1960 AND 1965

---- -------- .. .. .. ... .. . ..... . .... .........a...a.a..........aS a...

I 1a9 01 19 I 9a21 1 9 31 1 9* 41 1 9 1 5 ISTATE .........................S ea.. a .. ...e . ............... a … e..

1 ClT. I 118C0I CUt. I V116.I CUT. I VISC.I CUt. I vs16.l CoT. I V18C.I CIT. I V1SC.1

- nAuNIAO I 42 1 0 3 1 0 1 259 1 41 1 170 1 19 1 515 I 309 I 115S 1 422 1-t1t1 I 11 I it I 65 I 0 1 43 1 244 1 3 1312 1 S1 435 1 57 1 326 1

- ClAM 1991 75 6$3 1 17 1 10 1 447 1 41 1 4431 1 72 1 294 1 $39 1 475 IsoI0 SUDI I 01 3I 0 15 1 2 1 22 1 21 511 21 211 21 321DOs0o30 1 1 1 1 I 1 1 I I I I I I

- 145ARA 5 23 1 22 1 1 15 161 72 1 1 113 1 14 1 136 1 33 1 251 1 58 1- 1ERNANSUCo 1 14 1 13 1 17 I 6 1 32 1 25 1 29 1 26 1 186 I 107 1 203 1 186 6- ALA* s IIs 1 1 1 20 1 6 1 13 1 15 t 27 1 20 1 335 23 1 9 1 48 1- S0ta1ls I 15 1 10 4 1 32 1 3 1 35 I S I 24 1 7 I 38 I 47 1 100 1-stA 1 430 1 4 1 83 1 1 1193 1 248 1 9 1 40 1 *0 1 237 1 1341 1 74 1- KNASI,AtISI 421 1 0 189 1 1 1125 1 41 13 l 1 0 1 251 1 9 1 350 1 22 1

1 1924 1 152 1 1710 1 336 1 1808 1 1099 1 1426 1 1095 1 1931 1 1720 1 4614 1 2425 1*....................................................... b.... b.. ..............................

- TOtL I I I I I ICUTANEOUS PLSI 2076 1 2048 1 290? 1 14068 1 3657 1 7239 1

V1$CI 4 ) I II*- .... ,...- s.a.w.. * ---.aU5an5*,5OOOa5-SaSSU5SeUaaa

-32 -

ANNEX 1Graph 1

BRAZILNORTHEAST ENDEMIC DISEASE CONTROL PROJECT

REPORTED CASES OF LESIMANIASIS

Brazil: 1979-8515 . ._._

-. 9Z9 1 98 1ss 19 1 1 9X 1983 1 984 7985

Year

33 - ANE 2Page 1 of 6

SMU USE OF PRSTICIDES

Row to Avoid Realth Risks and Protect the Enviroment

General Priucinles

All pesticides are a risk factor for humn beings and animals, butthere is a difference between the intrinsic toAicitv of the product and thedaner they represent. lighly toxic preparatioons are not used for vectorcontrol due to the difficulty in reducing uman exposure to them.

O" way of esasuring the potential toxicity of a pesticide, especiallyin relation to hUmU and other ammals, is to estimate the quantity oftoxic component per kilogram of body weight needed, either oraly or dermaly,to kill 502 of experimental animals, generally rats and occasionallyrabbits. This is called the average lethal dose or LD 50. Toxicity may varyby way of ingestion or contamination, or by fonrmulation of the product(liquid or solid). Based on these considerations R10 has established tablesfor the toxicity and degree of danger of pesticides, under the qualificationof highly haxardous (BB), moderately hazardous (NH), slightly basardous(SE), and unlikely bazardous (DU).

Based on sueb caracteristics of toxicity, health programs classifypesticides by risk groups, from I to IV, recomeuding not to use the groupsI and II, and to use when possible groups III (slightly hazardous) and IV(unlikely hazardous).

Studies on toxicology indicate that products belonging to the samegroup, like the organophosphorus compounds (0P), have a different degree oftoxicity. For example, Pmrathign, which is used in agriculture, is the moretoxic with an LD 50 for rats of 3 mg/kg of body weight (oral dose); whileTemfibos (Abate R) has an LD 50 for rats of 2.600 mg/kg (oral dose) and4.000 mg/kg by denmal contamination.

Anoterr OP is Malathion, used for public bealth in Brazil, having an LD50 of 1.000 mg/kg of body weight (oral dose) in rats, and over 4.000 bydermal contamsination. kowever, inadequate storage in tropical areas mayallow changes in the chemical composition of the product, transforming itinto lsomalatbhi. hich is highly toxic. An accident of this kind occurredin Pakistan in 1976, and 2,500 workers (sprayers) of the malaria controlproject becam sick, of whicb five died.

Except for pirethroids and regulators of insect growth in the larvalpbase, few insecticides have been incorporated in the Brazil controlprograms.

Besides toxicity, another feature to be conasdered on cbemicals is thevay it is used, i.e. typ of formulation; concentration; method ofutilization; accidental food exposure; abosece of labels; inadequatelabeling either because of its content'or the lagusge used; contaminationof the barrel or boxes; inadequate storage; illiteracy; lack of proper2training; or lack of information of the beneficiaries. Very frequently the

- 34 - ANNEX 2Page 2 of 6

population is aware of the danger related to the ingestion of an insecticide(orally) but not of the danger of its aboortion througb the skin,particularly in bot climates.

Control of Eademic Diseasge

SUCAM is responsible for the control of Xalaria; Ch&a^s Disease,Leisbauaiasis; Schistosomiasis; the control/eradication of J. aegvyti and A&albouictus in order to avoid the urbanization of the yellow fever of theforests and to control dengue; peat control; filariasis bancrofti control;study of filariasis by O. zol1uluM; goiter control through the supply ofiodine to the salt packaging factories it associa.ion with INAN; monitoringiodine content of the commercial product; and finally coordination of theprogram to control soonoses in urban areas,, particularly rabies and kaslasr.

For the control of major endemic diseases, SUChM applies, among othermeasures, organochloriue compounds, organophosphorus compounds, pyrethrum

compounds, moluscicides, raticides, and other cbemical products known inBrazil as "dislodgers" to facilitate the inspection of walls in order toidentify triatominse.

The most common pesticides used by SUCUM are:

Produet Igulatioa Protram

1. DDT Powder/bumidifiable 752 Malaria-Kalazar-LTA*2. DDT Technical degree 98-1002 Malaria-Ralaar-LTO*3. 8BC Powder/hum.30Z iso. gamma Ralazar-Pest-Chagas4. liclosamida Powder/bum. 702 Schistosomiasis (snails)5. Deltametrina Imuls. conC. 2.52 Chagas Disease6. Deltametrina Powder/hum. 5,02 Chagas Disease7. Cypemetrina Powder/bum. 40.02 Leisbmaniasis (Kalazar,

LTA)8. Cyperuetrina Pqwder/bum. 40.02 Test!pulicide/Pest9. Jenitrotion Powder/bum. 40.02 Leishmaniasis-Aedes10.7enitrotion ULV-GT 952 Nalaria/Aedes/Culexll.Kalathion hmulsionable concentrate Yellow Fever/Dengue/

Kalazar12.1alatbion ULV-300-1000 ml/h Malaria/Yellow Fever/

Dengue/Kalagar13.Pirisa 10/80 aerosol Triatominae dislodger14.Temefos Granulated 12 (lppm) Larvicide/Aedes/Yellow

(abate) Fever/Dengue

* American Cutaneous Leisiabnisis

Sme Insecticides like NBC, XCI (Lindean) are seldom used now, andotbers bave been used in a lesser ecale, like the Carbamates (Carbion,fevin, Carvin, lorvin) as pulicides for pest control.

ANNEX 2-35 - Page 3 of 6

The raticide "1080" or sodium fluoracetate, was used for the pestcontrol program, but it bas been now discarded due to its high risk; and hasbeen replaced in the program by Brodifacoum (Klerat-R).

The use of iusecticides in a program has also favorable effects inotbers. For instance, the increase in control activities for A-desd aestiand Aedes albonigtus contribute to the control of Leishmaniasis vectors,thus allowing a ebane in the work plans and goals of the latter.

Pesticides like chloropyrifos, malatbion, diauinon, fesitrotbion andcarbamates like carbaryl or propozur inhibit the ch1iaueltgzase thus it isessential to control cholinesterase levels in the workers using pesticides.It is also advisable that new vorkers hired for the application ofpesticides (organophouphorus, carbamates) be tested for Cholinesterasebefore starting their work in public health, as frequently they areoriginally from agricultural areas where intkrventions witb organophosphoruspesticides like parathion may have affected their blood levels ofcbolinesterase. It is also recomeanded that SUCAN spraymen be provided withsifficient water and soap to wash themselves at frequent intervals.Facilities must be available to enable them to take a bath or shower at theend of a days's work.

Main Identified Problems

1. Storaie Facilities

Imported druge arrive to preselected ports (Belem do Para in the North,and Paranagua in the South) and are quickly distributed to the RegionalDirectorates, and from there to the Districts. Storage facilities vary fromdistrict to district, but in general they do have minimal conditions forstorage. Sucb conditions should include: (i) stand or wood platform to avoidhumidity and allow air circulation; (ii) free space to allow air circulationover the boxes or barrels; and (iii) some security elements or padlocks toavoid free access to the public.

Instructions erlst, but in general at a peripheral level of the systemthey are not followed. It bas been observed in a district, during non-working hours, that boxes witb pesticide have not been kept in the storage.

2. Handlig at Storage Level

Instructions exist and are adequate, if applied with discipkine.henever boxes are damaged, but tLe pesticide is in good condition, it is

repacked. If there is contamiation or mixture witb the soil, the product iscollected and buried in areas where it could not barm the population orsources of water.

3. Acquisition and Supply

Apparently the system of acquisition and supply of pesticides does not

AlNNEX 2- 36 - Page 4 of 6

follow a standard pattern in relation to the packing and labeling of theproduct. To illustrate this point:

DDT in powder bumidifiable at 75S arrived from Indonesia witb labelswritten in Englist in the boxes and in the plastic bags containingindividual packages (670 gr) prepared in the factory.

DDT bought from Italy had Portuguese labels in the boxes, but therewere no individual packages prepared at factory level.

DDT from Jamaice had Inglish labels in the boxes, but the individualpackages in plastic bags had no labels at all.

The sixth edition of the WHO book on specifications for pesticides usedin public health, 1985. details the content of eacb label, depending on theproduct or its formulation. It is recomeanded that such label be in thelanguage of the country where the product is going to be used.

4. Guidelines and Manuals

Personnel from the National Healtb Council of the Ministry of Healtbhave prepared a manual in Portuguese on Pesticides in Public Health. Themanual is very useful but needs to be reviewed and updated to include newproducts that are being used and also indicate the risk factors identifiedin some products after the manual bas been published.

There are no manuals suited to the use of medium level personnel or forperipheral field workers. The sprayer's manual bas not been updated.Corrections are usually made tbrough circulars for each program, and this isnot functional for an integral training of SUCAX workers.

The Regional Directorates and Tecbnical Divisions at beadquarters havenot bibliography on this subject. Spanisb being a language easily understoodby high level staff, it is recommended to use material already available insuch language prepared by the Pan American Center of Health and HumanEcology, Pan American Health Organization, Vetepec, Mexico. This materialcould easily be translated into Portugupes and adapted to SUCAM needs.

Some titles include: 'Risk prevention in the use of pesticides" (1983);'Pesticides: risk prevention in its use - Training Manual", second edition(1986); "Prevention, diagnosis Dnd treatIent of intozications bypesticides", 1. Plestina (aareb, Yugoslavia), (1986); and "Classification ofpesticides according to its dangerousness", MD0 (1986).

5. Traina Courses

SUCAN baa sent eploycs to Pauw- to attend a course called"Tecbniques on Pesticides Utilisation, and Equipuent Use and Maintenance".organized by OPS, the University of Panama, and the Ministry of Healtb/hSEM.The last course was in Novmber 1985. SUCAM has also organised local courses

ANNEX 2Page 5 of 6

- 37 -

on the same subject, especially in relation witb LECO equipment for the antiAades aeislti program. lowever, no courses bave been organized forpesticides bandling, and prevention, diagnosis and treatment ofintoxication. In 1985, SUCAN and OPS have contacted UNICANI/Sao Paulo withthe purpose of preparing some courses on the subject, but it bas never beenimplemented due to lack of funds. Botb the personnel of SUCAX beadquartersand in the Regional Directorates agree on the need to give bigh priority tothis type of training.

Options for Solvina Id ntified Problems

1. Inter into an agreement witb an entity In order to review existingusterial and to prepare new material in Portuguese, to be used atRegional, District and field levels.

2. This entity would organize the following training activities:

(a) A three-day seminar, for the Division Chiefs of the three endemicdiseases included in the project; the Regional Directors of theNortbeast States and Nina9 Gerais; and the Field Activities Cbiefs ineach Regional Directorate. This first seminar could take place inBrasilia, DP, or in Cempinas, SP, and would include subjects like thesafe use of pesticides, prevention, diagnosis and treatment ofintoxications. The seminar would belp to motivate managers, and toreview the material prepared by the entity in order to introducemodifications if needed.

(b) Training 40 General Inspectors, in two courses for 20 people each,in places to be determined (i.e. Fortalesa or Salvador).

Activities under (a) and (b) would be undertaken during the first yearof the project, with the active participation of the contracted entity.

(c) Re-trainiig seminars for Inspector Generals would take place in thethird and fiftb years of the project, and would be given by SUCANpersonnel, for groups of about 20 people.

3. During the process of procuremet of material, adopt the technicalspecifications of VW on formulation and packing of pesticides, and onlabeling of boxes aDt individual packaging is the lapguage of thecountry. Each label sbould include warnings concerning the toxicity of

bch product.

4. Include in CUAN's rules and rgultions, the obligatious at eacb levelto comply with the onor of bealtb risk prevntion for the workers andenvironmental pollution.

S. Give one Loviboad kit to eacb district for cholinesterase control ofworkers, aod of members of the comunity wbere activities are takingplace that would bave accidentally been exposed to pesticides used bythe progran.

- 38 - AME 2Page 6 of 6

6. Eacb district sbould bave an emergency kit for cases of intoxicationsand clear directions on wbat to do and criteria for referral to higherlevels of care if needed.

7. At the Regional Directorate level, maintain contacts with otherentities dealing with bealth and enviroment; i.e.:- State Foundations for Inviro_ment Engineering (133(L), of the SpecialSecretariats of Enviroment;

- Enterprise of Techaical Assistance and Rural Extension (SK3A!Z) ofthe Ministry of Agriculture;

- Universities, especially Departments of Preventive Medicine andOccupational Healtb; and Toxicology;

- National Institute for Quality Control of ealtb (IJCQS), OsvaldoCruz Foundation, Rio de Janeiro;

- Pharmacy Schools;

- Foundations on Security and Labor Medicine (ia ig.), dependingfrom the Ministry of Labor, and existing in each State. Thesefoundations give seminars for the "Internal Commissions for Preventionof Accidents", knovw as CIPAs. The 20 hours CIPBeR courses fit thenieeds of eacb State, and emphasize legislation, labor medicine, andevaluation of risks. They are basically oriented to the industry, butmay be useful to some hierarchies of SUCAM.

8. teep the commuity informed on the precautions in the use ofpesticides, through the normal channels of SCAKM for health educationand social participation.

ANNEX 2

-39 - Table 1

NORTHEAST ENDEMIC DSLEASS CONTROL PROJECT

PiOPOSED ACTIVITIES

SAFE USE OF PESTICIDES IN THE ENDEMIC DISEASE CONTROL PROJECT

Years Tota TotaACTIVITIES ~~~CZ# US$ACTIVITIES 1 2 3 4 5 x1 000 xI

_-

a. Contracting revision andupdating of training materials,prepare manuals and participatein activities for staff training 300 300 16,760

- _--

'b. Seminar for higher levelstaff (Directors, Chiefs FieldOperations and 3 Dlvision Directors 267 267 14.916

c. Two courses of 20 participantseach, for General Inspectors

.566 _ 568 31,732

d. Refresher courses for 40General Inspectors _ es 1.136 63,44

N-TOTAL 001 $ 1,135 _ 5SS _ 568 2,271 126.71

Go 40 _it. Lowibond 300 300 16,760Suppies 71 71 3,967

SUB-TOTAL OF MVhSfSIL 371 371 30.727

TOTAL 568 _ 5C5 2,642 147,591W- - - - -

07Ak66

-40 - ANNEX 3Page 1 of 3

II1Y MFIOILIZATION W

1oam gbJegive

The objective of this cponent is to pramot beavioral chnge in theNort tern population aimed at reducing the risk of contracting anyone ofthe three diseases included in the project.

strateis

In order to attain a behavioral change, the component will develop twobasic strategies: a) popular education through schooling groups nd localorganizations; and b) health promotion through umss media systems.

1. Popular Fducati

The strategy of popular education consists in the develoipent ofw;orkshops and non-forual information and motivation activities for schoolage children and adults, on means of preventing the three diseases. To that-Ai SUCAN will produce materials like handbills for oollective use,

ansn p rencies for overhead projectors, and will have paper, paints, colorpencils etc., for the expression and creation of students. Students wouldthen have the role of motivators of their parents, who in turn would proposeindividual and collective alternative solutions. The work to be developedwith students would aim at the gradual inclusion of prevertion activitiesinto the curricula, allowing an active participation of teachers andpromoting institution building of educational work.

2. Health= PEtmton tha Mass Meia

Siimltaneously to the populwr education activities, and aiming at a100 coverage of the Northes3t population, a mss media campaign based onsocial marketing criteria would be designed and implaunted.

According to the utilization pattern of ass media in Brazil, radio andTV would be priiarily ued, sqpptd kw calnudar ad other printedmaterials. Ther will be four messagesr by cp4sn ammiallI in all the massmedia, and an adJustuut in the anuwl production to take into account theresults of the campaign. A survey would take place in order to make a choiceof the breodoasting stations and optimal hour. Three VTR Vrogram a year offive minutes duration on the suJect of the three disses would beprepared, to be used by the *6bile teems.

It is already knomn that a high p entage of the cominity is familiarwith ideal patterns of behavior that would alow them to avoid the diseass;but it is also clear that those behavioral patterns, do not belong to thecultural characteristics of the popultion, and thus are not adopted by thecomunity. It is necessary to propose smething new and practical througheducation and healtb promotion, or there is a risk of promoting bhavioralpattes that are already kow but not adopted b the comity. Th

ANNEX 3-41 - Page 2- of- 3

proposed swvey would try to find out why the cummity has not adoptedthose beavioral patterns, and to establish with the commnity alternativesolutions that the groups would acoept.

To that nd the suwvey would design a poll, interviews and workshopsfor the oinmity to discws erAemic dise_se and way to avoid them. Theidea is that both the criticisms and the proposals be gathered and used as astarting point for prmtion and ducation strategies.

Sm pilot localities would be selected in the project areas, weredetailed survey and training work would be performed, in order to establisha starting point for a more c sr-behsive work.

Taking into account the type of survey proposed, the sample would notbe probabilistic becusme it is necessary to control special cultural andepidemiological variables. The selection of the sample as well as the choiceof the instrumnts to be used and the training needed, would be developed bythe coordinators at central and regional levels; the latter would beresponsible for the selection and training of the survey interviewers ineach Directoarte.

teInmut

To implament this component, the necessary inputs have been included infour categories:

1. The project would finance salaries and per diems for 21 middle levelteochnicians that would back up the work of sanitary extensionists in the 10regional directorates, and 22 drivers of mobile units who would al8o act asauxiliaries for education activities. Per diems would be available for saidpersonnel and for 92 technicians alread working in the project areas andfor regional ooordimtors.

2. supplies for field offices and field work would include materials foractivities to be undertaken with students and cainity organizations.

3. Audiovisual and printed reproduction equipaxt for the ten regionaldirectorates and headquart rs; and 22 vehicles carrying audiovisualeguipt to w t the work of the sanitary extensionists. They would bedistribud according to the size of the directorates.

4. Csotractual ervices to be entered into for the production of educationsterial, printed amterial, broadcasting and audiovisual materials,acoording to SUCAM's ainistrative nacrs and the World Bank Guidelines. Inall cas", the responsible for the promotion strategy would orapvise theworbs and accept them for reproductict and broadcasting. Prootionalaterial would be contracted through local ocopetitive bidding. The

contracted agency would produce and pretest iaterial according to terms ofreference prepared by SLCWAN staff. Consultant services will include four Dmnmonths per year, of an IEC specialist, during five years. Perdiems forsupervision, and sminars for evaluation and adjustments of the projectwould als be financed.

- 42 -ANNEX 3

Page 3 of 3

tMgaive Activ,t,d

WbO analyzing the rofls iiw the c@mmity 1_ not yet adopted theprodoed bvior t It saoetim fwd that other roblem apar to beawe myount for the eople, and that they do not consider preventiveactios a priority. Por ths reson fidig will be povided to the regionldirectso, In an inzp.ital basin, to finrwe ¢mmity activities of aprodtive te or comditiond to cdinity prticiation in the solution ofa sanitay prlble related to the bmvuticn of admic disess

lteinsmg Evaluation

Monitoring of this ctonmt would be ensred throg incewsdsupervision activities frcm the cutral leel to the regioal directorates,and fram the latter to the districts. Behavior is not subtantiallymodified in a short tem. For this reon an evaluation has been incledonly to detemine the copletion ad timeliness of activities of thiscomponent, at the wd of the secoid yea of the projet. By the end of theproject, a survey similar to the a- pefonred at the beginming would try todetemine the behvioral modificatios acoomplished by the project.

rAnA A U8tzA¢;Ao CNt srAAl - wFo$*AA;O,ECACAO E t¢mACA(IECI

~~ -. .. ttloPO ̂ "0 I P"o 2 ^"0 s ^"0AN 3 AN 4 A11160 -AN***~~~~~~~~~~~~t im _118 -r t- .Xet. .... 1 fZI a rs* 0nlll l T m AMGA1411, rnwm_..

mrrr ^ H iE X + ~~10- n++ **n fLIii

Jl_~~~~~~A aI_* I I i

_ 0^ s s s E _ X T E | TrI I I A I tI 1

t -Illkilill . X~~~~~~~I- -1 I i tFIM i lTllllll_ _1 s r X rs rl T _ XT l l l I fi | X r I | s fi X z E E l | Iz z z z ii i i s

g _S II 1 tI e:t X+ TlI 4 Tr i- 11f 1 F II IlLfoo _IPllUJb.1+ . lzl l+Iilil qii

* . § s E | Z s 1 X r mr Tr , l I ,~~~~~~~~~~~~~~ I TTIfI

a -awJ - _ IIUIee lllL 11|11+ftllirllar

Fb__ t & fM Ili9 Mi§|§TII1dFIL

ttaml. a I I Io I r I T l II IL - I I

tswtxt it IlSllt- !ll5e IIl-tlIillr l I!!r

, ~~CRONOGfUAMA DE ATIMIADESPARA A MoB1zA<Ao C0MUNltAR1A - FoRmAcAo. EDucA4;:Ao E comuIcAIAo (IEC)

ATIVICADES TEMPO ANO I ANO 2 ANO 3 ANO 4 ANO 5 AN06

BtVtOllDES __ _ mtt4|5ls t sIs 2 I A114tstet"to 9to-t 11 2134 MIIM02 I 2135e e! e@ S16f tili X4111 11215 11Sl^1TIOleX1lU 1|tst154tlft

TEX1EA J1"NAS E - II1 ||I

~~~~~~111!§|IIwa l_Km DE MOELOS DE AlrIVI I1- r IIL 1Lt

f~~~~~~~~~~~ CI IAIW 1 1 LI I I I I i _ I I I t i I I 1 I i I I I at1

1111's.0, 11!. -Mi.r-arllee 1111lllllll -111t

_9)PVMf. |E ||t IE A | X § |. L XT I IIIff{|u

FM as iU-I 111 1 t IT I Ir l4Et&1ttlll11nli1§ L |Efi' 1i1

_^_ _ Rt5ULt OOS W X X v H ~If IfI ! I I 1 I1I.III I

- W M I P E A )ISCA . I I I A -1111;111LILLL

O8ENEY ~~~~~~~~~~~~~~It SI I I I I1llI111111IIIIL 1L IIIIL 1

_mow cs otesuLmon0 tS "

- rxm, w sr _wilh

I I - M OM AD Ni UCmI I Yesr I ew I Year I

1 1 1 2 3 4 5 NM1 1 2 3 4 SiuM 1 2 3 4 5iL I

IWareimo 1 368.5 168.5 166.5 166.5 118.0 792.0 1 30.0 2D.0 14.0 14.0 9.8 77.8 1 0.6 0.6 0.6 0.6 0.6 30 1

Iii.,i 1 22.0 2.0 22.0 22.0 15.0 103.01 1.5 1.5 1.0 1.0 0.7 5.71 0.1 0.1 0.1 0.1 0.1 0.5 I

ICeare I 235.0 235.0 235.0 235.0 165.0 1105.0 1 23.5 2.5 16.5 16.5 11.5 91.31 0.5 0.5 0.5 0.5 0.5 2.5

IDG.*di e I 93.0 3.0 3.0 9.0 65.0 437.0 1 27.5 27.5 19.0 19.0 13.0 106.0 1 0.2 0.2 0.2 0.2 0.2 1.0 1I I 1 I I -uraih 105.5 105.5 105.5 105.5 74.0 496.0 1 51.0 51.0 35.0 35.0 25.0 197.0 0A4 0.4 0.4 04 0.4 2.0 I

6ftw*=.o I 330.0 330.0 330.0 330.0 231.0 151.0 1330.0 330.0 231.0231.0 160.0 32.0 1 0.8 0. 08 0.8 0.8 4.0 1

0A1a~ms I 182.0 1820 182.0 182.0 128.0 856.0 1140.5 140.5 96.0 98.0 L0. 55.0 I 0.9 0.9 0.9 0.9 0.9 4.5 I

lpRI'e 1 95.0 95.0 95.0 9.0 67.0 447.0 1 99.0 99.0 69.0 69.0 48.0 31.0 1 0.6 0.6 0.6 0.6 0.6 3.0 1

13.bd 1 662.0 116.0 1114.0 1114.0 UD.0 4932.0 1565.0 1010.0 803.5 523.5 421.0 335.0 1 0.9 0.9 0.9 0.9 0.9 4.5 I

IWO" Cas I 483.0 933.5 923.5 923.5 736.5 4000.0 1355.0 605.0 567.5 437.5 32.0 2387.01 0.7 0.7 0.7 0.7 0.7 3.5 1I _ _ _ _ _ ~~~~~~~~~~~~~~ , . I I _ ______ _

YU!

AMNE 4_ 46 - Table 2

MRAZIL

Nortlmt ndemic Dis .e Control Project

TAMIMS BY ATIVITi AND BY YEAR: TMISH NIMIS

Rua reeniai -- l-3 toealth Education:flme Visits * 4.1300 4.130.00 4.130 4.130 4.130.000 20.0000

* School lectures I 2M 2.320 M20 23320 23320 141.002. DOR Scr :

Number to be tested .49.401 149.402 .3.4 t.42 1.492 7.467460

* Numbr blood samples 1.4&4 A 2 1.402.492 1.43402 14. 492 7.467410

* Ski snips 1id 61610 59.740 2167 14*3 337.024

3. Phlebotomlnae Screni:' lmber of home

vsttS 14.0 140 14.0 140 14.2 72.6

4. tat Actmtides:Number human exudatesto be examned - - .

Number canine xudatesto be me t1.ed 1.44 1.U4M2 1.493492 1.4ft4W 1.493.492 7.46, 46

(Expected positives) (lam (161 (19.740 mm*0 ( ) (337.024)Smears to be examined 143 .10 W740 2O.70 14.935 33 7024

(Expected positives) (~o') (MU (3WS) (0.1715) (0*57) (222.04)

* Phlebotomlae to be 20 00 32.ot 220 22.0 ¶10000csuif led

• Dog5 to be lpuinatd .73 179.0 19430 .740 .M7 674.*m.se to b spayed $*Ad4 ON" 134 33.67 GLS 2411.7M

Zola-Agar cases treated 3.0 30 240 *.m 710 ¶2.70

* LTA case tzieted 53 6A13 5.24? 4.01 2015 24.466

* Nmber of Glucantim mps. m00 63 4220 351X0 217.500 2.235.960

* Includes Infomatioa on risk factors sod control of LeuM4nass, humascreening and reerral.

- 47 -

BRAZIL NORTEWT ENDEM4C DISEASE CONTROL PROJECT ARE 4Table 3

5CISTOSONIASIS

TIH LE BY MGMA PASE AND BY YEAR

abaft Pm rom - AM Am **

_ft_ _Mom .~~~~~~..... .mt

fmmPouf

ffim- - - --

~~~ - - m-rn mi_

NA.m

- ouwm wfo ANUMMm -

cowe m m- iWn___-

* suAWM AWA%mmirnmmii

-aa -- dMW. mmm_

bm~~~OLm %m mini man ammumm

to - - - e-~~~--. .ni .

MW ~ -VA m m in-w

A vm - .e -

AUbm Wrn m m ai

cow* SO - m-aimmum

I pa-umto O - - -m~~- .e--em.m

~~iEm- -

Thss ff9*f.aa.v 00 *ak o utlM

- 48 -

Dawn ANNU 4IOR1 T AT UDDl(C DISEAS CONTROL T Table 4

TIMTABLE OF ACT!vmES

Federal Year 1 Y"r 2 Year 3 Yer 4 Year 5hits WSUCAR Districts b- semer-

lot 2nd A q 2,d ljt 2nd _.atud lot 2yAPdar a B B B to *........chanaedza a a a a B B o..o...o...Cady1 a O B B B * ....... **.

~~4zs1Xas * B B B 8 * ...... *.....

PSatb C a a a a * ... ... ... ...PXWI~~~~~ ~~ cl B B a a a... .* ... ........

RIO Gi00 m a B a a aBd p a . * *** .t.oo.......Sda1 a a a a a B *** *** too *..

tabia° a a a B a too * ......._ ~ ~ ~ ~ ~ t _ _ a a a _ _ ****

. sxoudtUpb a B. a a a .. .. * .. * .*.......ca±oB a a a a a * ... .. .. ...PAdak I Ama a a a a a * ... ... .....

e~naa a a a a a * .. **¢ .*. .-.Vit&.i dontomti a a a B * .. ... .*.

dag.io .d a a a a * ... ... ... *..fP Dpa a a a a a - . *** **d *d * ...i dos Palm a a a a * ... ... ...

bt^i a a a a a ... * ...... ;~A.Sra.d S a a a B * ...........

a Jva a a a a * ... .. .*. .;ie aaq a a a aw a * ... ... .....Itabaaa a a a a * .*... ... ...

Ci5 a a a a a *............

CA N J a a a a a,7nfi ° a a a1 a * ... ... ... ...~~1O~i. a a a .. ** .. 99

Cooenctis: a - Prepratory Phase (mapit, traffng, iWnuts distributio, etc.)b - AttacL Pbase (Ustowlogcal suvy, do testig/oll-Iatima,

insectic"de spraying*_ - luatiSlepostinn

P- oet eaalatio activities: Focalnsecticide Sprayin&dog tt l t - Swellmice

- 49 -

suzu ;AMI 4ois? uac QIDSi C=mO ICOI Table 5

TUAZt SiMY I tI, IUJCT CWOUT MD ITEU 0 IXPUDtTUR3(In s DOSlWs)

........................ ..... . ............................... , ,,,,,,,,,,,,.,.,....................................................................... It oll I No. *U I sulattOg I stssit £stQUtalgts I toslSCtOt t3at1t13 s213 I 10*2 I13*3 1 C@3g9031336 I I................. I................. I I lP*ItIZCtIV*3b (3*16) I 1ta Otntt I 164i111 I pgg stu4 I 21A*3 I COSTS I..................................... .......... ............ ............ ............ ............ ............

13*v 1 1- C3*0*31 0t33311l 1 I 2 la I II Uts6*Wt .... I 13 I 33 1 64,443 I 62.632 I 6X33 3 663 I 63.336 1I 310db Le tve I 201 61 62 ,201 I 62.966 I I I 56.169 I1- I tt$gF"t^*t I o I I I I |

I. 6C1IONZ*621*tI It 1 It t,$ t101 l,* I lt* I I t,4 N isbe Level O 30 160 I 613,253 I 6534 I I I 615319 I

I i Addle &*wet I 51 I 333 I 6330@,po 1 $63033 I $3.633 I 6636 I 0)31.333 1

I Level I I I I I I I II-LfSRIS$66 II I I " I I SSl1 $S.4 I WAddleLevel I 11 6 36333 6.3 493II 66.6

I I I I I I I I

I Ni6e Level As I 36 I $16,1st I 662,026 1 $691 1 6393 I $$*,90 I

-**331 101*3. I 2663 I 9)6 I $966,611 I 625,493 I $13,206 1 $6,546 I 61,012,096 I....... ........ ............. .............

1t**3 1- Cll&C0*'Ot3U6 I I I I g B ie Le1vel 0 12 1 4 0 $I,1.3 0 $0 62,9 6 $6,?32 I

I- ICsSsOs e I I I I I I Imiddl*e S.9.t 1 633 I is I 62M,s6 I I 6,*4 2 *S 652 $2723,93 1

I I I I I I ~ ~ ~ ~ ~ ~~~~~~~~~~~~ I I

I-couuuutly I ~ 30I I St*2I $251I WOI $31I $ 4II* eoncabe Level 20 1 6 I 82,662 I $2,"3 I 6230 I 6.23 I 63.614 II Ise t I * I It** I It$1 I s s?l *,1

1- ^t tOt *4t . .. .. ,. .... . ............... .O .. ,.............. . . ...TM 631-C3a6sI6t"S I I I I I I I

I isbee Lievel I Is I 4I St,053 1 62.493 I S66 I 663 I 62,.2 II 2iddl evetl 2I 6 I 620l I ,"S I $66, I0 I

' Ulebee Level 201 6 I $2*,2S 1 $2,6*3 I 6220 I $6323 $$,6 II "to I I I I I I I I

Agog"0at S t I is I 65.90 I $6.93 I 62,6 I $614 1 626,349 1

S IU ("* g I s8 it"62)I I S 5 , I t 5&gm: rev" I to I $$,"SI I $II I $ I

I. *133*3 101*2. I 22 I 16 I 13696 I 6II,00? I 64,16 I 6,,,,,, 14 69,539 1*- p --- * -------. * ------.*------ . -----....... - -... .-

111I(6*tt t, *3 I I I I| I I*$ I Il*$| $*^| $sz

I 3I 3 I I I 1,401 1 *t,lY 2 I

6 * 3 a 0t O t a I 3666 5 1001 I 1$ 53.99 1 624"6 I 616,624 5 693,212 5 61.42,401 I*~~~~~~~ * - - I . _-.I I | I-- -**-_-*--

- 50 --50- ANNEX

AE MDmUC D1MOCl. I Table 61m OF civ vs

I 1 1987 I 1988 1 198 ITASK$ l I __--_I

33 14 1 2 3 4 1 1 1 2 1 3 1 4 1* ~ ~ ~ ~ I II -- I- I_I-I -I-I -I_I_I-, I

1. Revispre1mi drad IMIn a I I I I I2. 1DI4 dad_s I I

a. District Office (?ztotype) PI mm I I I I Ib. iomD Ditote MI =I I I I

3. Se1acti/Catctiofd Cm t I I I I I4. 11v of P mtp and Fl D RlaI -I I I

5. Site kAsi _ol eallatibn a ImrIaI.............I.......... A I6. W;Xt_~~~I I D tI I I 6. aiftidDoamts aaugjIZ u

7. BidlBabstim IDRI I mm I I I I8. World Ec_App1a1 11 1 I9. Cact/statCM1 l a IaI 1 1= 1

10. &ipe,is of Civil Waft I - --- 1

U1. 26 Civil Mklu Ctut i la ----------------wrilhas~~~~~ In I I_

13 u .te, 1Xi1 bid 1z =I3Ai.h , I*ism I If I 1 I.inin1.I 1 I

S/ Dmtim to WM by Prfeitmb/ Ihistratin In OM?esp - Iepmble

* D - Iqimin Dizinctowte=F - Priva kcbitetsM VbrldPo11 - city o.ntnm

ANNEX 4Table 7

=M =MC DU= OM=m&Ias euird by Each a=o Pr I

TYPE

Vu. Pic-p Jep N*m lie

QbS! aOwf.l 13 - 1 - -Scdlttomissis Oto1 - 139 7 320 1,542lalaIiaes ieCo.l - 137 23 50 -

13 276 31 370 1542

notg,st mwgmm anu US;aV% r'stw uV* 90 6wt owl; mg as mg L, era

rtca % os a n's i anisa; - O-N- rnarn - iS

- - - - - - - - - - - . - -m - - - - w'Om rVWVOK uWsa Kv $W Ita a GI a is a a atm Mrait a an 6 a u -w osn'u at 0- aW a sm, r rn

wis twoS aft' - Awm U - at GI - ist M4 dm i ofu m

:1Us'a SWS ;6451~iS 05--U n 5 5 S W'9 WAiaCM' IdIW 9U';VWyin'; us'. ss' us us'. SS~S fP S i s O s r' -W -AIW WM -(3a

* -- - - - - - wp~t .. - L.rSWa u- -- - - -~~~ ~~~ ~ a - - - u, oug, *- -* - - -~~~ ~ ~~ ~ - - - - ow o 9qn raaY'- -- - - - ~~~~w - atel- ar VI - q wr, * in- -- - - - ~~~do - O aa - aw - i IMret

PMU 6w9 i'S -e - f £ -S Om. Ow us;waaAs "MM MPWt OM t Srua Sa';us'; in - S: : - @9 eVauIWVii w ism

96,af aftr' a afts M--ll--rns- -

rag min $Ws'; w - i' on - rn -t MOM-eV syua~~ AD hhc'- -w an - - -……-PP a PPa of

rm- -o $W is -f du On……ota - of a - 1w rrnVaw at WA a rn' u a r's; 5- - at-an rut's 001

rat an5' US'S an K'S a aU - K S-at- is aKI Wwa4t GP'aWstua Air$ us'; - -s uW a Sg a - rnj 0- £- Was/Wti TJNI'M 9 V*WC' ofi ofa r i' -- -at S .n i . . . .5' iYI. aWU"' rnat uGin aum'gift 0 aftE ussum In rn as *S - - v '- 03mrsmc as'; mYW; P wn'S a U a- - Of-rn - is r Wua/w' Iu la I -mvcla as' os's gy's a u-u- - . 0n-rn 0- is 1 WW"48Ms'u ="mm mgVOK awls m5';u Swif a u a u - at -is 0is ao'g/iw .iUl' Snlt s" rnl at - - rn - - - is at aet- -i Ow -wrd WAqsrrIa Um'f W t 's 's aft - so - a w e-uLa - w6v 6- - - Ms*us anY' KYWs KY - Ut - a - - 05 -0rn- is9 6v wii WtsM'w 1 rts

risc as'; It in iSW$ - a - St - - 0a - rn- volts' sa/ua'unss miAris I'm

rs "i s*s vij Gift SI - U- a a - s s M' saasiucP' ~I mrts LuW; 155' in %Vs a - a - - s- s - is us't waaw wII s ampT roi a

- is is - - - is -- ~~~~ ~ - at - - Om- Ow W I-witaw ram twituVnW s $WC - us-a urn- - oV - - wa -tmis au's us'cm aft u m m aa - la, - -r -p s is;uoaaS' '09V Vs" ass' us; ia w' - - 5 . 0- owls' Wioiaa'ita ftl @eVoS'l atwsawL;l LV; u-- - r-r-'W -i aW a9/ -ma r p

655t as Sw?pn l - ca's MOI'st rae writ uisv a a A" 3W -l --- ;uaj - VUsftio uP1~i4m IV ass tags- jws - - -- a a LD/'a9 i~~5s

- - -- - ………… - 4 - .wau~~~~mo nw'*I p

nag aim;US'S in v u-u - n- is P'; a'o r i- --- 4um SVSIlOD M * 6m4g

- - - - -…-~S.wi -- - is - - - is - - - tv " O IE

-52-

ANNEX 4Table 9

BRAZIL

Northeast Endemic Disease Control Project

CQrtional Performanie xndicators

Dispersed ClusteredIndicator Population Population

:1. Average number of houses sprayed/trip,

2. Daily average of houses sprayed/guard

53. Daily average of stool tests processed/lab. technician

54. Daily average of treatments administered/,

5. Average number of dogs tested/trip

.6. Daily average of household visits/guard a I

7. Monthly average of dogs eliminated/ ' a aI No. tested positive

i8. Average cost per case diagnosed * j a a

19. Average cost per case treated * j | j

* These indicators will be obtained through a special study financed aspart of the operational research component. SUCAM and the Bank wi ll agreeon reasonable improvement and monitoring of performance indicators.

-53 - ANNEX 5Page 1 of 2

BRAZILNORTHEAST ENDEMIC DISEASE CONTROL PROJECT

AIDS COMPONENT

Main Enidemiolosical Features

Although the largest number of reported AIDS cases is still in theUnited States, Brazil is one of the many other countries in which thedisease has developed into a serious public health problem. Firstidentified in the country in 1982, AIDS has increased rapidly in subsequentyears, with total reported incidence as of end-1986 more than doubling to1981 cases by July 1987. Particularly high rates have been noted in thecities of Sco Paulo (26.7 reported cases per million population) and Rio deJaneiro (15 cases per' million). Although. incidence of AIDS is higher inseveral other countries, Brazil's reported caseload is now the secondlargest in the world in aggregate terms. Moreover, after accounting forundiagnosed and unreported cases, actual incidence of AIDS in Brazil isprobably higher than the official estimates.

As in the United States and Europe, AIDS in Brazil occursprimarily among homosexual and bisexual men, intravenous drug users,hemophiliacs and children born to infected women, with a rising incidenceof heterosexual transmission. 82.5X of patients are in the 20-49 agegroup, the years of peak economic productivity. Infection occurs via theintroduction of the HIV virus into the bloodstream, with the subsequentformation of antibodies. Although not all those who test positive for thepresence of antibodies go on to develop AIDS symptoms, current technologiescan at best postpone death after actual onset of the disease. While nosystematic efforts have been made to estimate the number of AIDS carriersin the Brazilian population as a whole, preliminary tests of blood donorsindicate a national sero-prevalence rate of 0.3X, with incidence as high as1.0 in large city jails. Hospital care costs of a patient with AIDS mayrange between US$40 and US$80 thousand. As carriers frequently do notexhibit symptoms of the disease, the possibility of a rapid spread of AIDSthroughout the population convinced Brazilian health authorities of theneed to mount a formal public healtb campaign in August 1985.

Component Obiectives

a.) General

- To prevent further transmsissiou of the HIV virus- To reduce the incidence of morbidity and mortalityassociated with the RIV virus

b.) Specific

- To implement and supplement an effective epidemiologicalsurveillance system

AMNE 5Page 2 of 2

- To promote educational activites addressed to the generalpopulation as well as to higb-risk groups, the media andhealth professionals

- To develop a training for health professionals, in the areas ofmanagement, diagnostic techniques and epidemiology of AIDS

- To encourage the carrying out of epidemiological andoperational research

- To implement Macro-Regional Reference Centers (Centros deReferjncia Macro-Regionais) in support of the AIDS Program

Main Comgonent Features

In 1988 and 1989, the AIDS component of the Northeast EndemicDisease Control Project will emphasize the following activities:

a.) Development of human resources, by adoption of a strategy designedto make health staff skills more responsive to AIDS-related needsat the local, regional and hospital level. Qualititative andquantitative shortcomings of current staff have been apparentsince preliminary AIDS conferences in 1986.

b.) Realth promotion, by means of an intensive multi-media campaigntargetted at high-risk groups as well as the population at large.Without resorting to alarmist appeals, the initial 24-month mediacampaign views the high-frequency disseminiation of preventivehealth information as the most effective means of changingpeople's patterns of behavior, and thus halting the spread of thevirus. All available channels of commmnication are to be usedthroughout the country, including television, radio, newspapers,magazines, posters, bumper stickers and fliers.

c.) Technical assistance. To develop an effective five-year program,two high-level consultants will be necessary. In principle, theseadvisers should be available for fifteen days per year over thetwo year period, with actual needs to be determined by the ProgramCoordinating Unit.

d.) Research. As the incomplete understanding of the actualprevalence of AIDS in Brazil has until now hindered preparation ofan effective strategy, targetted epidemiological research specificto the country is of utmost importance.

e.) Laboratory support to facilitate control activities, particularlyas regards quality control of donated blood. Of the estimated300,000 episodes of blood donation occurring monthly in Brazil,only lOZ are currently tested for transmissible disease such asAIDS, syphilis, malaria, hepatitis and Chaga3's disease.

- 55 - -,gm Table 1

so= am=a= a

m mic - M

~~I ~1= 1 1I I I I l l I I

I3mur 2 1*A1. I I 13.1c I*m3w c I%1bc I II 1 _ S 1 I 1 S 1 I1a I

I1mul 1 6 60.01 7 53 .1 3 3.91 76 67.91 27 0.21 86 42.61

Its_,a1 1 2 20.0 1 33 28 1 319 19.11 17 15.21 12 214 1 383 19.31

hlatruwim DM U I - - I 1 0.81 39 2.31 6 SA I 1 1.81 47 2.41I~ I t Il I I I

Ille11c I 1 10.01 6 4.51 S1 3.11 1 0.91 8 14.31 67 3.41

!1_1 1 - - I S 3.81 19 1.11 - - I I 1.8 1 25 1.3 1I I I I I I I IIlaaoo Trani-m I 7 5.3 1 S2 3.11 5 4.5 1 1 1.81 65 3.3 1

I I I I I I I Io I - -I - - 1 5 0.3 1 2 1.8 1 2 3.6 1 9 0.5 1I I I I I I I Ibbtam I 1 10.0 1 8 6.01 87 5.2 1 2 1.8 1 4 7.11 102 5.11I I I I I I I IIl I - - I 2 1.5 432 25.9 1 3 2. 1 - - 1 437 22.11

I I 10 100.0 1 133 100.0 1 1670 100.0 1 112 10.0 1 56 100.0 I 19 100.0 I__ _ _ _ _ _ _ _ _ _ _ _ I _ _ _ _ _ _ __I _ _ _ _ _ _ __I _ _ _ _ _ _ __I __ _ _ _ _ _ _ _I _ _ _ _ _ _ __I I__ _ _ _ _ _

Iomme: Po m lciml e Cd roe a de 5 . A ie.seivico da slidw cia * Itatstica

----- -- -S-X-ff-r-- -- ---

[F ~~ -i -| - - - --- ---- 5l -1 -i

I I

!i~fLiFF

- 57 -

ANNEX 53PAZl fTable 3

UrAI? UIUIC DS in§a

- -Om 806 3 c A MR 1987

O198 199 II- 1 I I I1. 1M Th=bh I , I 1,2S3,53* 4 2,506,800

12. Mm Vdiia lith Ptb im 1,024,639 i 1,024,639 I 2,049,278 |

13. Teebdcal asistace | 30,000 I 30,000 I 60,000 I

14. lb3nb I 140,000 I - 140,000 1e I I I I15. Blood Teat lqlpremt ad Eeguts t 2,610,577 s 2,610,577

16. Office Iquipmt (Ctmal and bhro I 98,620 1 - I 98,62D IIqimo OffkcesIII I E fI I II

17. L&muma7 t dpit for 1tional 34220 - I 342,200 1mm 54"436b7s84 I I I I

I loA 5,499,436 I I 7,807,475 II _ _ _ _ __ .1. _ _ _ _ 1 1___ _ ___

- 58 - AN

Table I

MIUhASI WEtNIC OIrStns Cstes. PROECT

PJtCT COTS Y CONwPt 0 CAtESltS Of tEtNEOTURlNOuo OF SsLMS

... .............................................. . .... ................................ ..............................................

! ! COIIPUSw l I TOTAL TOTAL! !---------I -***-- ----------*--...........................- . *- ........ .................. ! PIROJECT SAS !

CA! EOOSI OF f tait 1 !. PtItEIOI a CONtROL Of twiis I tt ! 111 IV ! V COSt COST!. IOTA. !Cafh! m. O PA. I ltit. ! 4103 !! ~ am ! ! ill1 ! UZS1)U ! C !OU . ull. !J A. I! ? ! c I !

....................................... . ...... .............. . ........

!1. IRVEStIU COSTS ! ! a ! ! ! ! !

- Civil Ok s 0.0 ! 0.0! 0.0 0.0 ! 0.0 t 0.0 13,620.2 ! 0.0 1!3.620.2! 6.!!* tEilwt d& Fifhtuit ! 7.4! 4,517.5 ! 29.9 ! 6,134.0 ! 310.1 ! 0.0 ! 1,tt1.l 1 21530. 11,007.5 1 5.5!

!* field lk 0.0 ! C,OO.C3 ! 4,210.6 1142.218.9 1.2M.4 ! 0.0 ! 0.0 ! 140.0 !143.64S.3 7 11.0! * teical Assist ! 27.9 ! 27.9 27.9 a .7 ! 44. 0.0 I 301.7 ! 60.0 4 490.1 1 0.2

! * taiuiI ! 47.9! 63.! 57 1.7 1,26.41 44 1 0.0 1 174.1 ! 2,506.0! 3,9"2.0! 2.0!* ProeSct Iplemtatia llit! 0.0 ! 0.0 ! 0.0 ! 0.0 ! 0.0 ! 0.0 6,361.3 ! 0.0 ! !! Publictiy/ Ndie I 0.0 ! 0.0 ! 0.0 ! 0.0 ! 5.00.6 ! 0.0 ! 0.0! 2,049.3 !*0.. * wcb Studi ! .0.0! 0.0! 0.0! 0.0 0.0 1 !20.0 0.0! ! ! !

! ! ! ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ! ! a ! ! a a a I TOTAL lKtSIt cOts %3.2 ! U.190. i 65,550.1 !140,703.0 ! 7.S46.5 I,S0.0 !22.29.1 7,406.9 !1N.46.3 ! 94.1 !

! -l gtal Staft ! 3.623.2 377.5 ! 0.0 4,000.7 ! 2.34.3 ! 0.0 ! 0.0 ! 0.0 ! 6.335.0 ! 3.2 !! * Coa tu S ic ! 145.3! 470.0 ! 0.0 1 1,44.1 .0 0.0 ! 1,031.7 ! 0.0 ! 2,41.8 1 1.2

!-Field W Swu lis; ! ! ! ! ! ! ! ! ! I !! ZVsicl 0e. a W t. ! ! . I ! ! ! ! ! ! !@ Others ! 1,.414. i 0.01 0.01 1 ,414.S ! 702.2 ! 0.0 407.7! 290.6 2,M.0 !!! ! ! ! ! ! ! ! a a a ! ! ! ! ! 3 I ! ! ! ! !

TOTAL . , I S11,.0 I 0.3 I 0.01 6,09.3 ! 3,036.5 i 0.0! 1,525.4 ! 290.6 11,721.0 ! S .9 !

10t1t M o OW CT ! 6,146.2 1041.0 t W. I6.11 I,S73.l 1 t5.O0 I 1,50.O ! 23,754.5 1 7,777.5 10.160.1 ! 100.01

|IPIIYSICI CUItIIIUICIIS 1 401.0 1 4,445.? ! 3,569,0 I 3,419.7 ! 542.2 1 0.0 1 1,074.1 i 1,074.1 ! 11,110.1 ! 5.5 !10Ct c!o o 230 I 3,142.2! 2,112.4 1 5,474.6 1 S2. ! 43.5 I .3 ! 424.3 1 6.749.2 1 3.4 !

0L 1 0 COT I 67.M.2 ! 91,62.7 1!2,.. 1 0,46.4 ! 11,107.71 ! 1,1S.5 I ,252.9t I 95.9 1211,047.4 ! 10.9 !!3 Of ON t tA.OOOT 1 St !0.2 5 .3 0.7! 11.6 ! 0,516.2 !! 1t30 1 404.6! 2,195.6 ! 4,057.4 t 6,737.6 ! 171.0 ! 0.0 ! 2,469.0 ! 2a4.0 1 1104! ,6.6 !9/13/07.......... _ .......... ... _ ... _ ... _ .... _......._..._

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

o~~~~~~~~ g. 4 q qf 9 A- E q -t R. R.

- - -- -n-- -N N -- _ N

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

dl U ) e tERtRg l ZS g 4

M if -~~~~M --- I -- -- - - -. --- -

X ! X " IM qt k § 9. q 4 RE R 4

.~~~~~~~~ ER 1.q94q E~~~~~1 a a A

-- ~- -- - ---------------------

J i 1 I I''i~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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

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

g% g

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

mb sIl1 S -VO I. _o . s- v °

_____________________-_-_-- …- __ I

0W )? ) W% )0%

24 " t " F u HF C ewe |---- -- - -- - ----------- --- -- -

_____________________________ ____I

-d - - - --- -- - - -_- - -- --- ---

I-- --- - - - - -- -" - -- -- -- -- -~ - g -f

ANNE 7- 61 - Table 1BRAZIL

Northeast Endemic Disease Control Project

Allocation of Loan Proceeds

Category Loan amount Disbursement(US million) Percentage

1. Civil Works 6.0 50%

2. Bquipment and Furniture 8.5a) Irc 1001 of foreign expenditures

100% of local expenditures(ex-factory cost)

b) LCB 50% of local expenditures

3. Chemicals and Drugs 28.5a) ICB 1001 of foreign expenditures

100% of local expenditures(ex-factory cost)

b) LCB 501 of local expenditures

4. Training. Research. Teecnical 6.0 100% of foreign expendituresAssistance & Mass Media for consultants hired abroad;

50% of local expenditurefor local consultants andother items of category (4)

5. wages 27.0 60% until disbursements havereached the aggregate of $5.0million; thereafter, 50% untildisbursements have reached theaggregate of $11.0 million;thereafter. 401 untildisbursements have reached theaggregate of $17.0 million;thereafter, 30% untildisbursements have reacbed theaggregate of $22.5 million; and25% thereafter.

6. Incremental Operating Costs 13.0 411

7. Unallocated 20.0

TOTAL 109.0

- 62 -

AM= 7'tb reZ

BRAZIL

Northoast Endemic Disease Control ProJect

ESTDIMTED SCHEDULE OF DISBURSEMENTS

Fiscal Year t Disbmenta 1 Acamulated LUndisbursed tDiBburaements blance

Saemter ihding amount x amount X amount X

E__ June 30\.1 8.0 7.3 7.3 8.0 101.0 92.6

EADecember 31 1.5 1.0 9.5 8.3 99.0 90.8June 30 15.0 13.8 24.5 22.1 84.5 77.5

December 31 15.0 13.8 39.5 36.2 69.5 63.8June 30 10.5 9.6 50.0 46.0 59.0 54.0

EMDecember 31 15.0 13.8 65.0 59.6 44.0 40.4June 30 11.0 10.0 76.0 69.7 33.0 30.3

December 31 14.0 12.8 90.0 82.6 19.0 17.4June 30 8.0 7.3 98.0 90.0 11.0 10.1

December 31\.2 11.0 10.0 109.0 100.0 0.0 0.0

1 Special Account deposits of US$4.5 million (CIBSA), and V1$3.5million (FluA).

2 Project completion date is June 30, 1993 and Project closing dateis December 31, 1993.

- 63 -

amAL AN! 8na am cM= -M = MTable 1

S=nrs ~mA~~ca=

I _I mXaPII - I

I aL II lm=

' ' ' ' I r l of I u I (

Dh1- 1 1.

rAk I I I I I

DW J l~ I, NIII

3__L,,, ,, I ,, I Iu.I

-- I C#JAE Ii..i.i00I IhL,,ffi,, 7Lw

a" ! t r- tI I _ _l

D -timo ault of Uuitmi

-u~uicy of MlIC o b Ceuffi u- ftblic akb Sde vcm_ de hatm

0f ~ iio of fo _ (Comdra di ~ra di Nojnto)

64 -A 8

nIJU 0011mo co

f WCAN S,UPRIIE NDENT

COGEP I TECNICALCOPLAN PEOJECT _ ADVISORY

MANAGER COMMITTEE

|ENDEMC DISEASE ADMINISTRATIVE PERSONL ADMINISTRATIVE-CONTItOL DAENT DEPANENT FINANCING

DEPARTllEtl DEPARr'! T

Chagas Division Transport Div. Recruiting/ [Budget Div.Schistosoui"as Div. material Suppl. Div. Selection Div. L. Financing Div.Leishuaniasis Div. ECounicationa Div. -Legal DivisionTechnical Div.

REItONAL DIECTORATES|

-laulRio Grande do NorteParaibaPernaucoAlagoaSergipeBahialungs Gerais

-65 - ANNEX 9

S3LECTED DOCUMHNTS AVAILABLE IN PROJECT UILES

1. Ministerio da Saude - SUCAMs Projeto de Controle de Doencas endemicasno Nordeste. June. 1987. (This document is intended to be used aspart of the Project Implementation Volume).

2. Ministerio da Saude - SUCAMs Projeto de expansao do Coutrole deesquistosomose no Nordeste. March 1987.

3. Ministerio da Saude - SUCAMs Plano Especial de Controle daLeishmaniose no Nordeste do Brasil. March 1987.

4. Ministerio da Saude - SUCAMt Programa de Kalazar: Plano de hmpausao.March 1987.

5. OPS/OMS Brasil: Projeto de Desenvolvimento Institucional da SUCAM.July 17. 1986.

6. Ministerio da Saude. Programa Nacional de Controle e Prevencao daSIDA/AIDS: Projeto para ser apresentado ao Banco Internacional deReconstrucao e desenvolvimento (BIRD). July 1987.

7. Cristalli, Carlos (Cover letter and attacbment). Parecer do IPLANsobre o Projeto "Endemia. no Nordeste." PARECER IPLAN/CSP No. 009/87.Junio 29. 1987.

8. WHO (1984): Chemical Methods for the Control of Arthropod Vectors andPests of Public Health Importance (chapters relevant to the project).

9. Reglamento Interno da SUCAM. PORTARIA No.161/BSB/76 Publicada noDierio Oficial de 26.05.76.

NOTES

MAP SECTION

lIORD

BRAZILNORTHEAST ENOEMIC DISEASES CONTROL PROJECT

o State Capitals Northeast Region Boundciry

* Notional Capital State Boundaries

International Boundaries

t VENEZUELA - klein PROGRAM FOR__ c UtA / } \S^ts LEISHMANIASIS CONTROL

I *n {' ZFREgHOWAN4 / Z ' .RA

Area of Maps NftalPARAARNH_

( < NORTHEASA S A g PiAUI ~~F * 9NO

B R A Z I L / 7 :-< E seGOIASU | ; t ?(* Atlantic

aBOLMA Baii

Atlantic Brasilia

. C X _#j 0PAIGUAI

Ocean oala

n'o A ' '. -- lINAS GERAIS 4 '

_/,,.fisiiin NPROGRAM FOR PROGRAM FOR| i' SCHISTOSOMIASIS CONTROL CHAGAS CONTROL

.S./y/,///fA/? I . I U*Cesd S V\ . ..!s p I 1 UtbdMAtAN

SAO PAULO [////../Xi ,Q-- >. . VO PARA

7/ _ _ * < A/ 7-

Atlantic ~ ~ ~ Hl"~Atlantic

Ot.lean Ocean

Nm Co" AWAft INAS GE1RAIS45P Z 1NwCstol ActMfl

SAO PAULO L9o #AS - 4 1o MILES> ~ ~~~ 0 40 KIOWSU 4KILOMIlR