Argentina - Population, health and nutrition sector review

Report No. 6555-AR Argentina Population, Health and Nutrition Sector Review October 26, 1987 ( ontr\ [Departiernt IV' ( lM.ffltrs Ope)traitl(ion, 1)X011O aItir' Ameri ,i .ndi the (aribbctan Regif wi ( )tt, e FOR OFFICIAL USE ONLY Document of the World Bank 1i !c d0( iunient Kmas a -stric ted di9t rihution aind maV b L'i Led by rVLipients onls I the periorman e of their ofti( W utieal. d t ( < ntents mnay not wthermvse he discl:noed without WVorld B3ank aUt horizati on,  CURRENCY EQUIVAI,ENT Currency Unit - Austral (A) Exchange Rate Effective July 1986: US$ 1 = .82 Austral 1. A -- [JS$ 1.22  FOR OMCAL USE ONLY MAIN ACRONYMS AND TERMS USED IN THE REPORT ANSSAL National Health Insurance Administratior (Administraci6n Nacional. del Seguro de Salud) CBR Crude Birth Rate COFESA Federal Health Council (Consejo Federal de Salud) COMRA Argentine Medical Association (Confederacion Medica de la Republica Argentina) FAM Drug Assistance Fund (Fondo de Asistencia en Medicamentos) FEMEBA Medical Federation of the Province of Buenos Aires (Federacion ei6dica de la Provincia de Buenos Aires) FTN National Drug List (Formulario Terapeutico Nacional) INFYB National Food and Drug Institute (Instituto Nacional de Farmacologia y Bromatologia) GDP Gross Domestic Product GMP Good Manufacturing Practices HS Health Secretariat (Secretaria de Salud) IDB Interamerican Developrent Bank 1MR Infant Mortality Rate INDEC National Institute of Statistics and Census (Instituto Nacional de Estadistica y Censos) INOS National Institute of Social Funds (Instituto Nacional de Obras Sociales) ISSARA Argentine Insurance Institute for Rural Workers (Instituto de Servicios Sociales para Trabajadores Rurales y Afines) MCH Maternal and Child Health MOE Ministry of Economy (Ministerio de Economia) MSAS Ministry of Health and Social Action (Ministerio de Salud y Accion Social) This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization,  MAIN ACRONYMS AND TERMS USED IN THE REPORT (Cont'd) NGO Non-Governmental Organization NHI National Health Insurance (Seguro Nacional de Salud) OS Social Fund (Obra Social) PAMI Medical Care Plan for Retirees and Pensioners (Plan de Asistencia M#dica Integral) PAN National Food Program (Programa Alimentario Nacional) PAS Assisted Health Programs (Programas Asistidos en Salud) PHC Primary Health Care SNIS National Integrated Health System (Servicio Nacional Integrado de Salud) TFR Total Fertility Rate UBN Unsatisfied Basic Needs  ARGENTINA POPULATION, HEALTH AND NUTRITION SECTOR REVIEW TABLE OF CONTENTS Page Ng. Executive Summary .... . . . . . . . . . . . . . . . . . . . . . . . i Focus of This Report I. SOCIO-ECONOMIC BACKGROUND . . . . . . . . . . . . . . . . . . . . . 1 A. Social Impact of the Economic Crisis . . . . . . . . . . . . . 2 B. Poverty . . . . . . . . . . . . . . . . . . . . . . . . . . 3 I1. POPULATION. HEALTH AND NUTRITION STATUS . . . . . . . . . . . . . 3 A. Population . . . . . . . . . . . . . . . . . . . . . . . . . . 3 B. Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 C. Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . 11 III. SECTORAL ORGANIZATION . . . . . . . . . . . . . . . . . 13 A. The Public Sector . . . . . . . . . . . . . . . . . . . . . . 14 B. Social Security . . . . . . . . . . . . . . . . . . . . . . . 15 C. The Private Sector . . . . . . . . . . . . . . . . . . . . . . 17 D. Coverage and Quality . . . . . . . . . . . . . . . . . . . . . 18 IV. GOVERNMENT PROGRAMS . . . . . . . . . . . . . . . . . . . . . . . 19 A. Primary Health Care . . . . . . . . . . . . . . . . . . . . . 19 B. The National Food Program (PAN) . . . . . . . . . . . . . . . 21 C. The Drug Assis'.ance Fund (FAM) . . . . . . . . . . . . . . . . 22 D. Mental Health . . . . . . . . . . . . . . . . . . . . . . . . 22 E. Laboratory Services . . . . . . . . . . . . . . . . . . . . . 23 F. Food and Drug Administration . . . . . . . . . . . . . . . . . 24 V. THE HEALTH CARE DELIVERY SYSTEM . . . . . . . . . . . . . . . . . . 26 A. Ambulatory Care . . . . . . . . . . . . . . . . . . . . . . . 26 B. The Hospital System . . . . . . . . . . . . . . . . . . . . I 27 C. Proposed Government Interventions . . . . . . . . . . . . . . 31 D. Towards an Implementation Strategy . . . . . . . . . . . . . . 32 This report was prepared with the contributions of J. Pillet, W. De Geyndt, W. McGreevey, P. Marquez, (PHND3); H. Dieguez, D. Jolly, and N. Hollander (Consultants).  ARGENTINA POPULATION, HEALTH AND NUTRITION SECTOR REVIEW TABLE OF CONTENTS Page No. VI. MANPOWER .... . . . . . . . . . . . . . . . . . . . . . . . . . 35 A. Medical Personne'. ... . . . . ............. 35 B. Nursing and Other Personnel .... . . . . . . . . . . . . . 38 C. The Costs of Manpower .... . . . . . . . . . . . . . . . . 38 D. Measures under Consideration .... . . . . . . . . . . . . . 40 r. Issues to be Addressed .... . . . . . . . . . . . . . . . . 41 VII. HEAITH CARE FINANCING .................... , . 43 A. Health Spending .43 B. Financial Flows in the Health Sector . .4 C. Issues in Health Care Financing ... . . . . . . . . . . . . 49 D. Proposed Government Interventions . . . . . . . . . . . . . . 52 E. Improvements in Health Care Financing ......... . . . 53 VIII. INSTITUTIONAL. CAPACITY . . . . . . . . . . . . . . . . . . . . . 56 A. Mana6,ement Analysis .... . . . . . . . . . . . . . . . . . 57 B. Issues in Management .... . . . . . . . . . . . . . . . . 61 IX. ELEMENTS OF A SECTOR DEVELOPMENT STRATEGY ... ..... . . . . 66 A. Strengthening Primary Healt.h Care ... . . . . . . . . . . . 67 B. Improving Hospital Efficiency ... . . . . . . . . . . . . . 68 C. Health Manpower ......... . . .......... 70 D. Financing .... . . . . . . . . . . . . . . . . . . . . . . 71 E. Institutional Capacity .... . . . . . . . . . . . . . . . . 71 ANNEXES: Annex 1-1: Goveriiment Spending on Social Program3 Annex 1-2: Strucutre of Government Spending on Social Programs Aminex 1-3: liouseholds with Unmet Basic Needs Ane.- 2-1: Demographic Trends Annex 2-2: Birth, Death, Migration, and Growth Rate-, 1950-2020 Annex 2-2B: Demographic Projections Annex 2-3: Population, Urban and Rural, by Province Annex 2-4: Age-Structure of the Population, 1980 Aiinex 2-5: Infant Mortality and Child Mortality (1-4) By Province Annex 2-E- Strucutre of Infant Mortalicy (.944-1981) Annex 2-7: Maternal Mortality by Province, 1970 and 1980 Annex 2-8: Food Supply: Protein and Calories Available Per Capita Per Day (1980) Annex 3-1: Estimated Population Coverage by Health Provider, 1980 Annex 3-2: Nui..ber and Population Coverage- of Social Funds, 1983  ARGENTINA POPULATION HEALTH AND NUTRITION SECTOR REVIEW TABLE OF CONTENTS (tont'd) Annex 5-1: Facilities for Hospital CAre and Ambulatory Care by Sector, (1980) Annex 5-2: Di-tribution of Health Facilities by Sector and Type of Service, 1980 Annex 5-3: Ambulatory Care: Medical Consultations, by Source of Financing in X Annex 5-4: Ambulatory Care: Medical Consultations by Provider and Provinces (1980) Annex 5-5: Ambulatory Care: Medical Consultations, by Place, in Percentages Annex 5-6: Hospital Beds by Provider by Province (1980) Annex 5-7: Hospital Care: Hospital Admissions by Provider, by Province (1980) Annex 5-8: Hospital CAre: Utilization of Public Hospitals by Province (1980) Annex 6-1: Manpower: Health Personnel by Category, By Province (1980) Annex 6-2: Admissions to the Seven Major Medical Schools, 1970-83 Annex 6-3: Utilization of Medical Manpower Workload Accurding to Years to Practice Annex 6-4: Utilization of Medical Manpower Workload Accorcing to Type of Practice Annex 6-5: Manpower: Number of Beds by Physician by Providers and Provinces (1980) Annex 6-6: Manpower: Budgeted Staff Positions by Provider (1980) Annex 7-1: Health Expenditures as a Percentage of Total Government Expenditure, 1976/1980-86 in Millions of 1986 Australs Annex 7-2: Health Expenditures by Provinces (1980) Annex 7-3: Health Expenditures as a Percentage of Total Provincial Government Expenditure 1976/1980-83 Annex 7-4: Health Expenditures: Out-Of-Pocket Payments by Households, 1969 and 1980 Annex 7-5: Social Security: Estimated Revenues for Health Care 1970-82 Annex 7-6: Social Security System: Revenue and Expenditure for Health And Other Programs Annex 7-7: Percentage of Distribution of Ambulatory Visits by Source of Fincnaing, 1960 and 1980 Annex 8-1: Ministry of Health and Social Action: Organizational Chart MAP IBRD 19737  EXECUTI"'l SUMMARY i. The Argentine economy enitered into a period of decline in the mid 1970's. Falling incomes and shiftit:g wealth eistribution hurt a large section of the population aggravating the longstanding structural poverty in the northern provinces and in the peri-urban areas of Greater Buenos Aires. Average 'nousehold income declined by about 20 percent in real terms during the last decade. Available iuform.ation also indicates that income distribution became more skewed during that same time period. ii. The protracted economic de-line and the austerity measures have had a particularly severe impact on the poor, ae reflected by indicators of employment, wages, and the volume of social services. Some 30 percent of workers in large industrial enterprises lost their jobs and real wages dropped 37 percent between 1974 and 1985. The real value of retirement benefits declined fronm 71X of the average wage in 1970 to 472 in 1985. iii. The health sector's share of public spending fell from 5.52 in 1978 to 1.8Z in 1984. In real terms, federal health expenditures in 1984 were no more than one quarter of those in 1978. Spending on other social programs also fell. The 1985 poverty survey, which indicated that 18% of the population had unsatisfied basic needs, emphasized the effect of the declining level of public services. iv. Health problems are in the center of current political debate. The pLesent Government has given high priority to the sector. Substantial progress has been achieved in a short period of time in terms of coordination between the public health services, social security and the private sector. The options for a reorganization of the sector are still being debated. v. In 1985, the Government carried out a comprehensive survey of the health sector with the collaboration of the Pan American Health Organization. As part of its dialogue with the Bank the Government agreed to complement the 1985 overall review. The Ministry of Health and Social Actiol, together with the Ministry of Economy identified four priority areas of analysis: (a) the health care delivery system; (b) health manpower; (c) health care financing; and (d) institutional capacity. Consequently, the present report, after a brief overview of the Population, Health and Nlutrition sector, focuses on the four above-mentioned a:eas. vi. By mid-1986, the population of Argentina was 30.5 million, of which 84Z was urban, the Buenos Aires metropolitan area alone containing 14 million people. Immigration, which contributed to the rapid growth of population until 1950, has subsided, and the annual growth of population has fallen to 1.6Z, second only to Uruguay's 0.7% among Latin American countries. Education and urbanization have helped to reduce the total fertility rate to 3.3 in 1984. The crude birth rate remained constant at 22.5 per thousand between 1970 and 1980 and increased slightly to 23.7 per thousand over the last five years.  - ii - vii. Until 1984, official population policy, strongly supported by the church and the military, was decidedly pronatalist. The present Government, although less pronatalist, has only recentlv removed the ban on family planning. The association of poverty, high maternal mortality and a high rate of induced abortion indicates an unmet demand for contraception, and that family planning and human reproduction programs should be allowed for socio-economic as well as health reasons. viii. Life expectancy is 70 years. The infant mortality rate is 34 per thousand, three times the average of industrial countries. Maternal mortality is still unacceptably high. Disparities in health between urban and rural areas and between income groups have widened in recent years. Diseases of adults and chronic conditions of the elderly are the main causes of death. The pattern of adult morbidity, similar to that ir. industrialized countries, imposes a heavy burden on health services and on the economy of the sector. ix. Despite Argentina's vast production of foodstuffs, food consumption has decreased in recent years, and the 1980 Census revealed the existence of poverty-related malnutrition. More recently, pockets of poverty in depressed industrial, and rural areas prompted the Government to establish a National Food Program which provides emergency food supplements to 1.4 million low-income families. The program has contributed to alleviate the impact of the economic crisis. Two hundred thousand families have elready graduated from the program, and the Government is presently reducing the target population and reorianting the interventions. x. The health sector is ccm'plex and fragmented. Largely autonomous public and private agencies have proliferated without coordination. Health care is mainly provided by the provincial public systems and an extensive network of private physicians and private hospitals. The Government finances the public services while social security and commercial health insurance act as third-party payers for private care. A loose social security system is composed of over 300 independent social funds managed by trade unions. In addition, some 3,000 mutual-funds and commercial insurance companies offer a variety of medical insurance plans. xi. The present system leaves large segments of the population without financial coverage. The social sec.urity system reportedly covers 22.3 million people, i.e., 74% of the population; however, because of double- counting, real coverage may not exceed 63%. Of the remaining 37%, only a small percentage can afford private medical insurance, and the rest -- estimated at 27% of the population -- has no financial coverage and depends on public services. xii. In 1984, the new Administration took a drastic turn away from hospital-based sophisticated care, and has set three definite policy objectives: (1) expanding primary health care programs; (2) improving the equity of the system by extending basic financial coverage to the~ entire population; and (3) improving efficiency and cost-contairment in health care delivery.  xiii. In order to put these primary health care objectives into effect, the Goverrnent is introducing nation-wide programs primarily directed towards low income groups in fields s'lch as primary care and public health, maternal and child care, nutrition, supply of basic drugs, and mental health. At the same time, the Government plans to improve the public health laboratory services and the food and drug administration. To further expand primary care, the Government will have to secure the active cooperation of the provinces and social funds in implementing PHC programs. xiv. As the next step towards greater equity and efficiency, the Govern-ment will have to address four serious structural constrainits. xv. The first is the inefficient: health cale delivery system. The top- heavy hospital infrastructure is obsolete and un(ler-equipped, and to make it reasonably efficient would require irivestment on a scale that cannot be envisaged under the present austerity plan. As an alternative, the Gcvernment: is considering an extension of social security coverage which would lead to greater utilization of thie existing capacity of the public and private sectors. At the same timne, thie Government: envisages a comprehensive reform of the management and finarncing of public hospitals to improve their efficiency. xvi.. The second major constraint7 is an oversupply of health professionals and a shortage of mid levol technicians. A surplus of physicians is aggravated by the rapid production of new medical graduates arid a shortage of niurses. In relation to D1DP, Argentina has more doctors thani any other country in t.he worlcl. The oversuppl-y of professionals has generated a supplier-irnduce(d demand for expensive advanced medical care and sophisticated technology. It has also deflected health services from primary care. These distortions have had serious economic and health consequences. Although these manpower constraints weigh heavily on most goverrunent decisions, the institutions of the sector have so far been reluctant to acknowledge and address the issue. xvii. The third constraint, if tEle fiTranCinlg of the sector. Health expenditures impose a heavy burden on the economy, especially in the context of the stabilization plan. Tot-al expend(it.ures for health amount to 7.1% of GDP. Of this 7.1%, public expenditui.Xes account for 2.1%; social security's health expenditures account for 2.6%; and household expenditures for 2.4%. Per capi.ta health expenditure has reachled US$16() in 1985, and such a high level. would normally be expected to secure m,uch better results, but the overconsumption of medical services and pharmaceuticals, the overutilization of sophisticated medical technology, as well as inefficient management and overbilling, indicate that muchl of t-his expenditure is wasted. The Government is considering monitoring health expenrditures and establishing cost-containment measures in thlE* uMbli sel.tor as well as in social. security contracting wi.th the private sect.or. xviii.. As a financial mecharTIis!m to iiii-ocove tlhe (quity of the system the G,overniment is considering expanding so( jal secirity coverage to the entire  -iv - population. A proposal for a National Health Insurance scheme is presently under study by congressional committees before being submitted for final consideration in 1987. Currently, the proposal is still subject to amendment and its financial feasibility has yet to be ascertained. xix. The fourth constraint is the limited capacity of the institutions to carry out a major reorganization. Public sector management has deteriorated alarmingly in recent years. The freeze imposed on recru,tment and wages has adversely affected the major public agencies of the sector at federal, provincial and municipal levels. Key managerial capacity for planning, budgeting, evaluation, personrnel administration and project implementation was allowed to deteriorate seriously under the previous military administrations; and is now being restored with great difficulty. xx. The Government's health policies are sound and consistent with the economic stabilization plan. However, in spite of the urgency to improve efficiency and equity, the implementation strategy still remains to be articulated. To address the major sectoral constraints, a set of policy changes to be implemented over a four-year periud is proposed. As a first phase, immediate steps ahould be taken in four areas: (a) strengthen Primary Health Care programs, including Human Reproduction programs, by improving the technical design and programming of PHC activities. Specific budgetary provisions should be made for provincial and municipal prime y care programs. Social security contracts for services to be delivered by the private sector, should include specific provisions for preventive care; (b) introduce basic measures to rationalize the health care delivery system by: (i) establishing a unit to plan and control investments in hospitals and high-technology; (ii) providing technical and financial support to decentralize hospital management; (iii) assisting provinces and municipalities in mobilizing local resources for hospital maintenance and renovation; (c) take the lead in an inter-agency dialogue on health manpower issues. The government should establish an intersectoral advisory committee to review current studies and experiences and prepare policy decisions to reduce the production of physicians and make efficient use of existing health personnel. Over the mid-term a formal plan for the adjustment of health manpower should be developed; and (d) transform, ovcz the mid term, the federal Ministry of Health, to assume all policy-making and regulatory functions required by a modern state. In a shorter perspective, the Ministry shcald improve its capacity in policy analysis, by establishing a specific unit for economic analysis in the Ministry of Heal.h to make feasibility studies for major policy proposals and to appraise investment proposals in coordination with the Planning  -V Secretariat and the Ministry of Economy. The Ministry of Health should also improve its coordination with the provinces and further strengthen the National Institute of Social Funds. Finally, the Ministry should strengthen its staff resources by upgrading its own personnel and by contracting staff resources from public and private agencies of the sector. xxi. Priority invostment requirements for the sector are for: (a) implementation of primary care programs directed towards underserved groups; (b) rehabilitation of basic public health programs, such as mental health, laboratory services, food and drug administration; (c) improvement of hospital management; and (d) enhancing the capacity of the federal and provincial ministries.  FOCUS OF THIS REPORT i. In 1984 and 1985 the Ministry of Health and Social Action, with the cooperation of the Pan American Health Organization, made a comprehensive description of the Health sector; health status, sectoral resources and programs. The report -- "Argentina: Diagnosis of its Health Situation," published in October 1985, provided many elements for the present report and greatly facilitated the sector review mission. ii. The present sectoral review will not duplicate the description recently completed but will focus on a set of issues jointly identified with the Ministry of Health and Social Action and the Ministry of Economy. Whenever possible, the present report will attempt to quantify problems as well as alternative solutions. Summary descriptions of the socioeconomic situation, health status and organization of the sector, will provide the basic information needed to address the four major issues jointly identified with the Government: (a) the rationalization of the health care delivery system; (b) the health manpower; (c) the financing of the sector; and (d) the institutional capacity to carry a reorganization of the sector. Finally, the report will explore the combined effects of the proposed interventions in these four areas may have on the development of the sector.  ARGENTINA POPULATION, HEALTH AND NUTRITION SECTOR REVIEW I. SOCIO-ECONOMIC BACKGROUND 1.01. The Republic of Argentina extends 3,500 km from the Tropic of Capricorn to Cape Horn; its climate ranges from subtropical to subarctic. The total area of 2,767,000 km2, high mountains in the west and plains in the east create a variety of ecological zones with rich natural resources. Until the Great Depression, agriculture and cattle-raising were responsible for the country's rapid growth. In the ensuing decades, the growth of industry diversified the economy. 1.02. Over the last forty years, Argentina experienced an unparalleled economic decline. Once considered the sixth wealthiest country in the world, it has fallen to 35th place. This experience differs from that of other countries in Latin America, which exhibited significant growth before the severe recession that started in 1981 and which, in Argentina, only intensified a long process of economic decline. In Argentina, as elsewhere in Latin America, the recession of 1980-85 has rivaled the Great Depression. 1.03. From 1973 to 1984, industry, manufacturing, and services declined and only the agricultural sector grew. Hence, the real gross domestic product (GDP) grew by only abcut 0.4% annually, well below the 1 6% rate of population growthi. From 1965 to 1984, per capita GDP increased by 0.3% per annum, compared with 3.3% for all upper middle-income countries. In 1985, Argentina experienced the most pronounced fall in economic activity in Latin America when GDP decreased by 3% after a partial recovery in 1983 and 1984.1 1.04. High and rising inflation during 1973-84 also contributed to economic stagnation. The annual rate of inflation rose from 24.1% during 1965-73 to 180.8% during 1973-84. Consumer prices rose by 430% during 1983, and by a further 700% by October, 1984. During the second half of 1985, a new economic program, the Plan Austral, reduced the rate of inflation considerably. 1.05. Per capita product in 1984 was lower than in 1970; it may be virtually the same today as two decades ago: Table 1.01: INDEX OF OUTPUT PER CAPITA AND ITS RATE OF GROWTH, SELECTED YEARS. 1950-84. USS OF 1986 Year 1914 - 100 % US$ of 1986 1950 148 1,552 1960 164 1.0 1,722 1970 206 2.3 2,190 1980 221 0.7 2,481 1984 195 -3.1 1.948 S)urce: Dieguez (1986). Reflated to 1986 prices by implicit US GNP price deflator. 1 ECLAC, on the basis of official information.  1.06. Argentina's external debt rose from US$12.5 billion in 1978 to US$50 billion in 1985, a more than four-foled increase. The ratio of total interest payments on the external debt to the value of exports of goods and services increased from 9.6% in 1978 to 54.5% in 1985. 1.07. Consumption and investment have declined steadily. Real per capita consumption, public and private, used as an indicator of the standard of living in the country, has decreased in recent years. It rose from US$1,622 in 1970 to US$1,804 in 1980, and fell to US$1,600 in 1984. Investment fell from slightly over 20% of GDP during 1971-81 to 12.6% in 1985 and in 1984 investment in machinery and equipment amounted to only 3.9% of GDP. Between 1980 and 1985, central government investment fell by 85% in real terms, compared with 43% in Mexico, 44% in Venezuela and 45% in Peru.2 In 1984 and 1985, public sector investment was less than half as mutzh as in 1977. A. Social lmpact of the Economic Crisis 1.08. The deepening of economic disorder caused the progressive deterioration of basic social services amid the increasing unnmet demand for more and improved education, health care and sanitation. Over the 1975-83 period, social public expenditures declined consistently. Under the new Administration, social expenditures -- except health expenditures -- continued to decline in real terms (Annex 1-1), even if social expenditures, as a share of total public spending, appear to increase because of the drastic reduction in defense spending (Annex 1-2). Declining government spending in social sectors, in conjunction with its regressive effects on income distribution, mayI very well hiave a long-lasting negative impact on social indicators. A recent study sthowed that the overall decline in investment, if not reversed, may become the basic impediment to future development of productive activities. It is also likely to result in higher unemployment.3 1.09. The crisis has affected the labor market in three ways: (a) by increasing unemployment and underemployment; (b) by increasing the number of self-employed workers which often amounts to disguised underemployment; and (c) by reducing real wages, According to the National Institute of Statistics and Census (INDEG), unemployment rose from 2.2% to 3.6% in the Buenos Aires metropolitan aroa between 1980 and 1985, and from 3.6% to 7.6% in other urban centers. Over the same period, underemployment rose from 4.5% to 6.5% in the Buenos Aires metropolitan area.4 In 1985 alone, the 2 ECLAC, Santiago, 1.986. 3 Dieguez, H., Social Consequences of the Economic Crisis: Argentina, World Bank, 1986. 4 Defined as the rat.io of the nulmber of individuals working less than 35 hours per week to the e(cornomically active population.  percentage of self-employed in the same area grew from 18.6% to 23.1%. Real wages declined by almost 50% between 1974 and 1977. In subsequent years, real wages rose slightly to decline again during 1982. In 1986 real wages remain far lower than in 1975. B. Poverty 1.10. The deterioration of economic conditions has aggravated the longstanding structural poverty found in the northern provinces of the country and in the outskirts of Buenos Aires. A 1984 study by INDEC identified 1.6 million households (22.3% of total households) as having "unsatisfied basic needs" (UBN). These households represented 7.6 million individuals, or 27.7% of the total population. (See Annex 1-3) 1.11. The broad categorization utilized in the INDEC study to classify a family as "poor" may have overestimated the population living in poverty. The figure of 5 million people (17% of the total population) who receive food supplementation (see para 4.10.), is probably a more accurate measure of poverty. 1.12. The INDEC study identified three groups with unsatisfied basic needs: (a) the "endemic poverty" group, mostly rural, in the northern provinces of Formosa, Santiago del Estero, Jujuy, Chaco, Salta, Corrientes and Misiones (see Annex Map); (b) the "new poverty" group wnich includes the victims of recent industrial lay-offs, young people finding increasing difficulty in entering the labor market, and retirees and pensioners whose incomes have deteriorated severely in recent years; and (c) immigrants. The last two groups are mainly found in the outskirts of Buenos Aires which contain the highest concentration of poverty in the country. Urban poverty is reflected in the unabated growth of low-income settlements in and around major cities. In the poverty belt of Buenos Aires alone, the population of the "villas de emergencia" or squatter settlements is e3timated to have increased from 40,000 in 1960 to 280,000 in 1977. 1.13. The disparity of family incomes is less than that of per capita incomes. There is a close correlation between poverty and size of household. The most significant variables associated with poverty are the dependency ratio and the number of children per family. The INDEC study showed that households with unsatisfied basic needs contain on the average more than twice as many children as othcr households, and that 9.8% of such households have five or wore children, whereas only 0.7% of other households have as many. In addition, hou.,eholds with seven or more members constitute 24.2% of poor households and onLy 5.8% of the remainder. II. POPULATION. HEALTH AND NUTRITION STA S A. Population 2.01. Argentina's total population, 30.5 million in mid-1985, is projected to rise to 32.6 million in 1990 and 36.5 million in 2000 (see  - 4- Annex 2-1). During 1973-84, the growth rate remained at 1.6%, the third lowest in Latin America after Uruguay (0.5%) and Cuba (0.7%). It is estimated that the growth rate will fall to 1.31% by 1990 (see Annex 2-2). If the present demographic trend continuies, the country would reach a new reproduction rate of 1 by the year 2010 and its population would eventually stabilize at 53 million see Annex 2-2B). Popu'.ation density, at an average of 11 inhabitants per km , is the third lowest in South America after Bolivia (5.0) and Paraguay (7.0). Population per square kilometer of agricultural land (16.0) is the lcwest in Latin America. 2.02. Industrialization was accompanied by large-scale migration from rural areas to large urban centers, which resulted in the concentration of population in metropolitan areas. In 1984, 83% of the population resided in urban centers (up from 76% in 1965), with more than 12 million inhabitants (39% of the total population) in the Buenos Aires metropolitan area alone (see Annex 2-3). 2.03. In a period of declining public investment in social sectors, rapid urbanization imposes severe strain on the infrastructure of basic services (housing, water supply, sanitation, health and education) in urban areas. Balancing the distribution of pcpulation over the national territory has become a dominant concern for the Government. 2.04. Immigration from Europe, which contributed to rapid growth until 1950, has long ceased. Immigrants now consist mainly of rural poor from Bolivia, Paraguay and Chile who tend to settle as agricultural workers in thinly populated areas or in urban poverty belts. The large-scalo emigration of the 1970s has also come to a standstill. It is estimated that, in 1980, 307,000 Argentine nationals were living abroad, up from 168,000 in 1970. This large scale exodus, the result of economic and political instability, included a high proportion of skilled professionals and technicians. 2.05. The 1984 crude birth rate (CBR) was 24 per 1,000 population and has hardly changed in 20 years. The crude rare of natural growth is 1.5%. The total fertility rate (TFR), estimated at 3.1 births per woman during 1960-65, increased to 3.3 in 1984. This rate is below the Latin American average of about four children, but is still highler than the average of two in Western Europe. It is projected that the TFR will decrease to 2.5 by the year 2000. The 1980 Census showed that low fertility rates are closely associated with urbanization (rural families had an average of 2.9 children compared with 1.9 for urban families), increasing participation of women in the labor force and female education (63% secondary school enrollment in 1981). Woman who had not completed primary education had an average of 3.1 children, while those with higher education had 1.2. Argentina did not participate in the World Fertility Survey and the use of contraceptives is not reported, however the CBR at 24 per thousand suggests a contraceptive prevalence of about 55% of married women in reproductive age with wide variation from about 30% in the northern provinces up to about 75% in the Metropolitan area.  . 5 - 2.06. Adolescent fertility has decreased by 25X over the last decade. The age-specific fertility for women 15 to 19 years of age was 57 in 1980 (as compared to 68 in Chile; 100 in Costa Rica; and 150 in Guatemala) and represents 8X of the TFR (as compared to 13X in Chile; 14X in Costa Rica; and 121 in Guatemala). Teenage pregnancy is not a nation-wide issue, as it is mainly reported in rural areas of the northern provinces and low-income groups in periurban areas. 2.07. Ahe narrow-based age structure of the population (Annex 2-4) has important implications for health and health care. Over the last 35 years, the age group under 15 years of age has remained between 30.5% and 31% cf the total population; however, by the year 2000, the expected decline in the birth rate will have reduced this age group to 28.51 of the population. The working-age group (15 to 64 years), which accounted for 601 of the population during 1980-85 (as compared to 671 for the average industrialized country), is expected to increase in the coming decades, although not as rapidly as the group over 65 years of age, which increased sharply from 4.21 in 1950 to 8.51 in 1985, and is expected to rise to 9.6X by the year 2000. 2.08. In 1985 there were 65.3 dependents (under 15 and over 64) for 100 persons of working age (Table 2.01). Table 2.01: AGE STRUCTURE OF THE POPULATION IN X AND DEPENDENCY RATIO, 1975-2000 Year 0-14 15-64 65+ Dependency Ratio 1975 29.2 63.2 7.6 58.2 1985 31.0 60.5 8.5 65.3 2000 28.4 61.9 9.5 61.4 Source: United Nations, 1985 The de2endenev ratio is lower than the average of upper middle income countries (721) and Brazil (721) but higher than Chile or Uruguay (59%). The peculiarity of Argentina's dependent population is the relative importance of the elderly. 2.09. While the dependency ratio is expected to decrease slightly because of declining birth rate, the dependent group will include a growing proportion of elderly people who will require costly medical care and social security benefits paid for by the shrinking employed proportion of the population. Unless retirement is delayed, the growing imbalance between contributors and beneficiaries will further strain the financing of social security.  -6- Population Policy 2.10. Government population policy is designed to: (a) maintain the current satisfactory rate of population growth; (b) maintain current fertility level in order to maintain a balance between active and dependent populations; and (c) distribute the population more evenly by promoting regional development, especially in the south, and controlling urban growth.5 2.11. The case for family planning and human reproduction programs in Argentina rests primarily on health grounds. Until recently, government policy was decidedly pro-natalist for geopolitical, security and developmental reasons. In the early 1960s a series of decrees offered substantial incentives for families with more than two children and made the provision of information on family planning, the delivery of services and the prescription of contraceptives illegal. Several research and service centers were closed. These decrees have been recently repealed but there is still some reluctance to discuss family planning issues. 2.12, While upper and middle income groups have easy access to fertility regulation advice through private physicians, lower income groups, which are at higher risk of maternal and infant mortality, have virtually none. Public hospitals and health centers do not provide family planning care; physicians working in public services provide covert advice and prescriptions in exceptional cases only; and Social Security pays for contraceptives in exceptional cases only. As a result, maternal mortality remains relatively high, mainly as a result of complications of abortions, which are conservatively estimated to number some 350,000 a year (see para. 2.20). 2.13. The lack of family planning services has also a serious economic impact on low income groups. The 1986 INDEC study showed that families fall into the "unsatisfied basic needs" category, not because of the low income of the breadwinner, but because of large numbers of children. UBN status implies inadequate education for children and adolescents and, later, limited access to stable jobs and minimum wages. The 1986 Bank report, "Social Consequences of the Economic Crisis" underlines the magnitude of the problem: UBN families account for 27.7% of the total population, 40.5% of the pre-school population and 39.4% of the school-age population. Family planning services would help to break this vicious circle of poverty. 2.14. Technical officers in MSAS as well as physicians in the public and private sectors fully agree that, for health reasons, as well as socio- economic reasons, human reproduction services should be made available through public health programs and public hospitals. Significant steps have already been taken, such as: including family planning advice in instruction manuals and terms of reference for community agents and rural hcalth 5 UJNFPA, Inventory of Population Projects in Developing Countries Around the World 1984/85.  -7- auxiliaries; introducing family planning in the discussions led by PAN in the poorer communities; and establishing post-partum and post-aborcum clinics which include human reproduction services in important public hospitals. Further steps are under preparation: sex education in schools and for the populatior, at large; the training of health personnel in human reproduction programs; and equipping primary care programs to carry out family planning activities. B. Health 2.15. The country shows two different sets of health status indicators and epidemiological profiles: the urban profile with a pattern of di-eases comparable to most advanced countries, and the rural profile which is typical of underdeveloped countries. Mortality 2.16. In 1984, life expectancy stood at 67 years for men and 74 for women, with wide disparities between provinces. Life expectancy is seven years above the average for middle income countries but still three years below the average for industrial countries. 2.17. During the last 20 years, infant mortality has been significantly reduced. In 1984, the estimated infant mortality rate for the country as a whole was 34 per 1,000 live births, down from 59 per 1,000 in 1965. This rate is one of the lowest in Latin America, half of Brazil's (68) but still higher than in Cuba (16) or Costa Rica (18). Regional disparities are striking. In 1981, infant mortality rates well above the national average were found in Salta (51), Chaco (48), Misiones (48), Jujuy (47), Corrientes (45), Catamarca (44), La Rioja (42) and Formosa (40), compared with 17 in Buenos Aires (Annex 2-5). A 1978 study in Misiones showed a rate of 35 among urban higher income groups as opposed to 156 among low income groups.6 2.18. The causes of infant mortality are changing and indicate progress. Preventable deaths have steadily declined to less than half of total infant deaths. Postneonatal mortality, an indicator of early infant care, has also fallen below neonatal mortality (Annex 2-6). In 1980, the percentage of neonatal deaths that could have been avoided by proper prenatal care was 2.3% nationally, but 10.9% in Formosa. The percentage of deaths avoidable by proper care at birth was 12.4% nationally, but 21.8% in Tucuman, while the percentage avoidable through early diagnosis and treatment was 25.9% nationally, but 40.5% in Neuquen, 39.4% in Misiones, 37.8% in Entre Rios and 36.8% in Chaco.7 It is not known to what extent infant mortality has continued to improve since 1980 or whether adverse socioeconomic conditions have affected the trend. 6 CENEP, Buenos Aires, 1984, 7 Dieguez, H., Social Consequences of the Economic Crisis: Argentina, World Bank, 1986.  - 8 - 2.19. Child mortality decreased from 3.3 to 1.5 per 1,000 over the 1970- 81 period. Regional disparities, reflecting socio-economic differences, indicate that in 1981 child mortality ranged from 0.6 in Buenos Aires and Santa Cruz to 3.9 per 1,000 in Mendoza and Salta. The first cause of child mortality was accidents (17.8%), followed by acute respiratory infections (9.5%); infectious and parasitic diseases (7.9%); congenital defects (6.0X); and malnutrition (5.8%). 2.20. Maternal mortality declined from 1.5 per 1,000 in 1970, to a low of 0.7 per 1,000 in 1980, a 50% reduction (Annex 2-7). In 1980, as shown in Table 2.02, the leading cause of maternal death was complications of induced abortion, followed by complications of pregnancy and delivery, toxemias, and hemorrhage. Among urban higher income groups, maternal mortality has decreased to levels comparable with those in advanced countries, while among lower rural or periurban income groups maternal mortality remains at around 15 per thousand live births. Table 2.02: MAIN CAUSES OF MATERNAL MORTALITY (1980) 197Q 1980 Cause of Death No. % No. X Abortion 213 32.4 171 36.7 Hemorrhage of pregnancy and delivery 116 17.6 71 15.2 Toxemia of pregnancy 109 16.5 84 17.9 Other causes 221 33.5 141 30.2 Source: Ministerio de Salud y Accion Social, Hospital statistics, 1985 2.21. Adult mortality reflects the aging of the population and is similar to that in most developed and industrialized countries. Table 2.03 shows the leading causes of adult mortality in 1981. Table 2.03: FIVE LEADING CAUSES OF DEATH, ALL AGES, 1981 % of Cause of Death Rank Total Deaths Heart Disease 1 29.0 Cancer 2 17.3 Cerebrovascular Disease 3 9.5 Accidents 4 5,1 Arteriosclerosis 5 4.8 All other causes - 56.7 Source: PAHO/WHO, 1986  - 9 - 2.22. Chronic conditions are the leading causes of death. Heart disease, cerebrovascular disease and arteriosclerosis all fall under the heading of cardiovascular diseases, which are thus responsible for an extraordinarily high 43.3% of all deaths and 52% of deaths in the 40 to 69 age group, a percentage significantly higher than in industrialized countries (US, 45%; Canada, 44%; Italy, 37%; Germany, 36%; France,27X). While in industrialized countries cardiovascular diseases are already showing a decline due to balanced diet, weight control, control of smoking and a healthy lifestyle, this group of disease continues to increase in relative and absolute terms in Argentina. MoLbid ity 2.23. Althuugh most tropical diseases have been controlled, two serious problems remnain. The malaria endemic area contains a population of 85,000. There are only about 500 new cases of malaria each year, mostly among immigrants. However, considering that 3.5 million people are at risk over a surface of 350,000 km2, malaria remains a potential public health problem, should drug resistance develop further. The country is consequently forced to maintairn costly malaria control and surveillance operations. 2..24. Chagas disease has been progressively recognized as a public healt.h priority. About 2.5 million people are infected in 13 northern and central provinces. Blood bank surveys indicate prevalence rates ranging from 6i