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World Bank Document 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.
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