PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB2448 AR Provincial Maternal-Child Health Investment APL 2 Project Name
Public Disclosure Authorized Region LATIN AMERICA AND CARIBBEAN Sector Health (100%) Project ID P095515 Borrower(s) Republic of Argentina Implementing Agency National Ministry of Health
Contact: Mr. Walter Valle Ave. 9 de Julio 1925 Argentina Tel: 5411-4384 6997 Fax: Fax: (54-11) 4384 6997 [email protected]
Public Disclosure Authorized Environment Category [ ] A [ ] B [X] C [ ] FI [ ] TBD (to be determined) Date PID Prepared July 27, 2006 Date of Appraisal August 28, 2006 Authorization Date of Board Approval October 24, 2006
Country and Sector Background
1. The proposed project is the second phase of a 10 year Provincial Maternal – Child Health Investment Adaptable Program Loan (APL), which, together with the first phase APL1 and a health sector adjustment loan2, is the backbone of the Bank support to the Government of Argentina’s (GOA) Health Sector Reform Program (HSRP). The main goal of the APL is to support government implementation of the Provincial Maternal and Child health insurance program (Plan Nacer), which is, a publicly financed Public Disclosure Authorized transfer mechanism built around a defined package of health services for the non-insured mothers and children .rather than a contributory health insurance arrangement. Plan Nacer objectives are to improve access to basic health services for the target population and to improve the incentive framework for efficient use of public financing in the public health sector of Argentina, all, contributing to reduce infant and maternal mortality in the country.
2. At the request of the government this second phase would merge the original second and third phases of APL including all 15 provinces not included in APL I. Merging of the two phases is justified on several grounds: (i) due to the significant structural changes APL I is triggering in the relationship between the federal and provincial level and between the provinces and health services providers in APL I, the government is eager to extend the program nationwide; (ii) Program design is seen as very successful due to the promising output results Plan Nacer has shown under APL I in its first 18 months of effectiveness; (iii) all provinces not included in APL I have strongly requested to be included in APL II and are well advanced in complying with conditions of participation in the program; and (iv) including all
Public Disclosure Authorized remaining provinces at this stage would consolidate nationwide political support for Plan Nacer, essential for its long term sustainability.
1 Provincial Maternal and Child Investment project 2 Provincial maternal and Child Health Sector Adjustment Loan
1 3. Health sector background: Despite Argentina’s recent rapid recovery from the deep economic crisis of 2001-2002, the impact of the crisis and the systemic problems it revealed in the health sector continue to affect the poorest segments of the population. Although the country has shown steadily progress in recent years through the implementation of Health Sector Reform Program (HSRP), Argentina needs to continue tackling structural problems in the health care sector. For example, low coverage with formal insurance has not recovered at the same rate as macroeconomic improvements and a large proportion of the population continues without formal health insurance coverage, hampering their access to health services, especially for the poor. Further, the need to improve the incentive framework for increasing efficiency is still a priority for the sector.
4. The institutional, financial and economic crisis has fundamentally changed the realities and the priorities of the health care system in Argentina. As a result, health policy goals in the short- to medium- term have been to urgently increase access to basic health services for the poor and socially excluded, while simultaneously introducing structural changes to the health care system with a medium and long- tem view to improve the incentive framework for efficiency, system performance and good health outcomes.
5. Even before the current crisis, Argentina’s health system did not perform at the level of other middle- income countries in the region (e.g. Costa Rica and Chile), although per capita public expenditures on health care had been well above that of those countries during the 1990s. Encouraged by a growing economy throughout the 1990s, Argentina invested heavily in reforms and expansions of the social insurance programs focused mainly on the formal workers. These reforms tended to meet the health needs of the employed and the formal sector but were only marginally successful in reaching the uninsured and the poor. As a result, in spite of historically high national spending levels and the installed capacity in the sector, structural inequalities generated lower-than-expected general health outcomes.
6. Health Sector Reform Program and APL1 Implementation Status: Since 2003, the Government has been responding to the new sector priorities through its HSRP, which comprises an integrated package of complementary policy reforms and actions that aim at increasing the effectiveness of public subsidies in improving the health status of the poor. The Bank has supported HSRP through APL I 3, approved by the Board of Executive Directors on April 15, 2004, which was a complementary follow-on investment project to the Provincial Maternal-Child Health Sector Adjustment Loan (PMCHSAL), Ln. 71990-AR, approved by the Board of Executive Directors on October 28, 2003. Both have successfully supported the implementation of the Maternal and Child Health Insurance Program (MCHIP, Plan Nacer), the center pillar of the HSRP.
7. Status of APL I implementation: In line with its poverty focus in health policy, the government implemented Plan Nacer first in the nine poorest provinces of Argentina (North West and North East regions). APL I has shown excellent implementation progress with 378,000 enrollees or an average of 45 percent of the eligible population in all nine provinces by end of June 2006. Until May 2006, APL1 has financed more than half a million antenatal consultations for pregnant women and more than 12,000 normal deliveries for the eligible population. APL1 has also supported a significant increase in performance of the provinces in the coverage of key MCH programs, increasing, for example, the proportion of women with early antenatal consultation from 10% of the eligible population to 40% (more than 80% of enrolled pregnant women). Concomitantly, with the implementation of Plan Nacer, infant mortality in the APL1 provinces has diminished by 15%. An in depth project evaluation is underway to determine how much is Plan Nacer contributing to such reduction, in addition to the contribution of an improved economy overall.
3 Provincial Maternal-Child Health Investment Project, Report No 27892.
2 8. The project has also disbursed to target and by June 30, 2006 had disbursed 28 percent of loan proceeds as verified by the Financial Management Report (FMR). The Plan Nacer was very well received by the provinces involved in APL I and the response for uptake by non-participating provinces under the first phase has been very positive for the second phase. Also all APL I participating provinces have implemented major structural changes in health financing and health service management creating an incentive framework for more efficient allocation of public subsidies. The proposed project would continue the developments started under the APL I and ensure that increased access and structural reforms reach all the provinces of Argentina.
9. Similarly, the introduction in APL I of performance goals for 10 key outputs and intermediary outcomes (trazadoras/tracers) that determine 40 percent of all transfers from the national to the provincial level, has proven fundamental in reforming how these two levels discuss maternal and child policy. The trazadoras system is described in details under the project description section below. Provinces have progressively achieved trazadoras. Of the full complement of 90 trazadora goals (10 trazadoras for each of the 9 participant provinces), achievement has improved from both, in the goal (percentage of coverage) to be achived and in the number goals being achived, which went from an average of 3 per province in the first evaluation period (June-August 2005) to an average of 7 per province by the September–December 2005 evaluation period.
10. All second phase triggers have been met. The current level of enrollment already exceeds the condition of the first trigger. Similarly, more than US$37.5 million or 28 percent of loan proceeds have reported been disbursed, which exceed the trigger requirements.
11. Thus, implementation of the Plan Nacer with the support of PMCHSAL and APL I has been in line with the HSRP objectives: i) to increase access of the poorest mothers and children to basic services; ii) to consolidate regulatory reforms in the social health insurance system to avoid negative spill-over on the public health sector responsible for providing access to services to the poor and uninsured; and iii) to trigger significant changes the relationship between the national and provincial levels, as well as between the provinces and health service providers, contributing to improving the incentive framework for efficiency and output and outcome results in the sector
12. The proposed project would now extend the coverage of Plan Nacer to the poor and uninsured mothers and children in the rest of the country (with a total target population of about 2.5 million mothers and children). It is expected also that the introduction of Plan Nacer to the new provinces would introduce the same structural changes APL I has supported in the northern provinces, including linking national level financing to health, nutrition and population output and outcome results, and the introduction of contracting between the province and service providers, linking financing to actual delivery of services to the poor population. Further, APL II would be complemented by another proposed World Bank loan for the Argentine health sector currently under preparation – Essential Health Functions Program – which would focus on strengthening public health surveillance and service capacity in the country.
Objectives
13. The project development objectives are: (i) increase access to essential health services to the poor population, contributing to reducing the infant mortality rate (IMR) and maternal mortality rate; and ii)ii strengthen the incentive framework for efficiency among provinces and service providers through significant financing reforms
3 14. The Plan Nacer (APL I as well as the proposed APL II) has a strong poverty focus. First, the program specifically aims to reach uninsured households, which are often unemployed or work in the informal sector. These groups have a much higher likelihood of being poor than the insured households. Second, the program is directed specifically to mothers and children, which (among the uninsured) are the most vulnerable groups. Finally, in this second stage, the MCHIP would be implemented in the remaining fifteen provinces of the center and south of Argentina that are the most populated in the country. These provinces include 25 percent of Argentina’s indigenous population--traditionally a poor and excluded group (75 percent are already included in APL I). The Plan Nacer would include special outreach activities to target these groups.
15. This second phase APL would cover the fifteen remaining provinces of the center and south, not included in APL I. By the end of the loan implementation of APL II (5th project year), 80percent of the target population would be covered and served by the MCHIP (more than 1.7 million beneficiaries in APL II and a national total of 2.5 million beneficiaries including APL I). The national reduction of the IMR would also be accompanied by a reduction in the variation of the infant mortality rates between provinces, further strengthening progress made under the first phase of the program. These differences have been up to 3 times between the lowest and highest rates between provinces. The program would contribute substantially to Argentina’s ability to meet the MDGs for health by 2015.
Description
16. The proposed project would closely follow the design of the APL I. In particular it would maintain the same general definition of eligible Population, the same set and definition of basic services package of basic health services), the same design on output based and performance based disbursements, and the same set of Trazadoras. The project would continue to focus on the maternal- child population without formal health insurance coverage, which are the poorest among this population with the worst health outcome indicators.
17. The project will include, exactly as in APL I, a conditional per capita transfer from the national Ministry of Health to each participating province to finance up to 50 percent of the cost of the basic health service package offered in Plan Nacer. As in APL I, disbursements will be against submission of audited enrolment lists (60 percent of the per capita transfer) and achievement of 10 output goals (Trazadoras) (40 percent of the per capita transfer).
18. The second phase of the program would have a total expected cost of about US$678 million, of which the Bank would finance about US$300 million (including unallocated and front end fee), and it would cover an estimated 1.7 million beneficiaries. The project would include the following components:
Component 1: Implementation of the Maternal-Child Health Insurance Program (MCHIP) (US$ 247.8 million of Bank financing)
This component would provide financing to support:
(i) Capitation payments for Plan Nacer services by the National Ministry of Health (MSN) to participating provinces covering a declining share of a package of basic service costs, calculated on a per capita basis (US$215.4 million); (ii) Equipment (medical, transportation and communications) for basic health care facilities that supply the Plan Nacer package; excluding civil works or complex medical equipment (US$14.4 million);
4 (iii) Technical assistance and training programs to the Provincial Ministries of Health (MSPs) to develop systems, instruments and skills necessary for implementing and running the Plan Nacer including, inter alia: development of annual performance agreements with the MSN and authorized providers; development and implementation of contracting and payments to providers; development and implementation of outreach and service delivery strategies and mechanisms to rural and indigenous people and other excluded populations (US$7 million); (iv) Training for health care providers in delivering the Plan Nacer basic services (US$1.4 million); (v) Information technology equipment and consultant services for upgrading and expanding information systems for monitoring the implementation of the Plan Nacer (US$5.1 million), including trazadoras systems and provider production data; and (vi) Technical assistance and training for the management of participating health service providers to strengthen areas including their billing capacity, development and implementation of provider data systems enabling (US$ 4.5 million)
Component 2: Strengthening National and Provincial Ministries of Health Stewardship Capacity (US$ 8.3 million of Bank financing)
The focus of this component would be to adapt the provincial ministries of health to the demands of implementation of Plan Nacer (information, managerial), including the start-up of the national and provincial health service “purchasing” departments (PHSPD) in the respective Ministries of Health . The installation and functioning of these departments would imply major structural change to the way provinces are currently managing the financing of health service providers, and these are essential to introducing a separation of purchasing and provision of services. These departments would act, for the duration of the project, as the implementation agency (unit) for the project but, they would continue as “purchasing agents” for the health sector after program completion. In practice, these departments are the initial structure of what most provinces expect to be the future provincial public health insurance organizations. The proposed loan would finance consultant services, investments in office equipment, and training services to improve the performance of these ministries in exercising the sector stewardship functions of the MSN and participating MSPs including:
(i) Reorganizing participating MSP’s , staffing and relationships; (ii) Improving epidemiological information, financial and human resource management systems; (iii) Completing studies essential for MSN policy formulation
Annually, the MSN and each participating province would agree on a technical assistance program for the province and the specific resources needed for its implementation. Those agreements would be included in annual performance agreements.
Component 3: Communications and Community Outreach (US$17 million of Bank financing)
To ensure the effectiveness of Plan Nacer, the Government would need to ensure that the target populations, particularly those who have historically been marginalized, have adequate knowledge about, and motivation to use, the services being offered. The proposed Loan would finance consultant services, incremental ministry operating costs, event organization and media communication services to support two main lines of communications including:
(i) Dissemination of detailed information about the program among major stakeholders groups (provincial governments and their populations, Federal Health Council (COFESA), medical profession, insurance agency managers and staff) including providing opportunities for feedback and dialogue. This would be, primarily, the responsibility of the MSN and the participating provinces; and
5 (ii) Community outreach to increase participation of the eligible population by providing practical information on (i) beneficiaries’ rights to services, (ii) the package of basic services included in Plan Nacer, (iii) methods of enrollment, (iv) location, times and names of participating providers, (v) media communication campaignes, and (vi) support to community contact groups responsible for disseminating information, as well as receiving and reacting to feedback to strengthen citizen control. It would also support the production and implementation of the communication campaign elements specially adapted to language and cultural needs of indigenous populations. This would be mainly the responsibility of participating provinces. Provinces would provide details of their community outreach activities as part of their annual work programs, covered by annual performance agreements with the MSN.
Component 4: Program Monitoring, Evaluation and Concurrent Auditing Systems (US$12 million of Bank financing)
The program would be expected to change the incentive structure for health services staff and facility managers and raise their accountability for achieving results. To support this, the ministries’ (national and provincial) ability to monitor, evaluate and audit performance would be strengthened. The proposed loan would finance information technology design services, software and equipment, training for staff at the MSN and MSPs to upgrade the monitoring of health provider performance, aggregation and reporting of information. It would also finance the costs of external concurrent auditing of key elements that underlie transfers of capitation payments as discussed below in the section on implementation arrangements. Lastly, this component would finance the project evaluation activities, including the completion of the baseline for impact indicators, and project impact evaluation at mid-term and closing. APL II would follow the same impact evaluation design under implementation in APL I (see box 2 below).
Financing
Source: ($m.) BORROWER 354 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT 300 Total 654
Implementation
19. The project would be implemented by the MSN, through the MCHIP national health service purchasing department (NHSPD) created in the MSN under the first APL. This unit also serves as the specialized project implementation unit, and will continue as the national “health service purchasing department” in the MSN after project completion. The MSN has legal responsibility for coordinating health policy and programs in the country. The NHSPD would be responsible for working with the participating provinces in the implementation of the MCHIP and the project. The participating provinces would be directly responsible to purchase the Package of Basic Services (PBS) for beneficiaries to achieve the project’s results.
20. Simultaneously, the Ministries of Health of each participating province (MSP), which have legal responsibility for assuring health care in their jurisdictions and specifically for providing health care for those uninsured by other organizations, would implement their respective activities through the provincial health service purchasing department (PHSPD), created as part of the structural reforms being introduced in health financing
6 at provincial level. As is be the case with the NHSPD, it is expected that the PHSPDs would continue as the provincial health sector purchasing departments once the program is completed. Sustainability
21. The Government of Argentina and the provincial governments are fully committed to the program as demonstrated by the effective implementation of APL 1 in its first 22 months since effectiveness and by the financial commitment of the provinces which are already financing 50% of the cost of the PBS under APL 1. Additionally, Bank financing for the capitation category would be on a declining basis beginning in the third year of project effectiveness, to ensure a smooth transition of provincial incremental financing.
Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP/GP 4.01) [ ] [X] Natural Habitats (OP/BP 4.04) [ ] [X] Pest Management (OP 4.09) [ ] [X] Cultural Property (OPN 11.03, being revised as OP 4.11) [ ] [X] Involuntary Resettlement (OP/BP 4.12) [ ] [X] Indigenous Peoples (OD 4.20, being revised as OP 4.10) [X] [ ] Forests (OP/BP 4.36) [ ] [X] Safety of Dams (OP/BP 4.37) [ ] [X] Projects in Disputed Areas (OP/BP/GP 7.60)* [ ] [X] Projects on International Waterways (OP/BP/GP 7.50) [ ] [X]
List of Factual Technical Documents (Pending, to be completed during appraisal)
Contact point
Contact: Cristian C. Baeza Title: Lead Health Policy Spec. Tel: (202) 458-0314 Fax: (202) 614-0523 Email: [email protected]
For more information contact:
The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Email: [email protected]
* By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties’ claims on the disputed areas
7 Web: http://www.worldbank.org/infoshop
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