Argentina - Public Health Surveillance and Disease Control Project

Report No. PID6803 Project Name Argentina-Public Health Surveillance (@+) and Disease Control Project Region Latin America and the Caribbean Sector Health, Nutrition & Population Project ID ARPE55482 Borrower Government of Argentina Implementing Agency Ministry of Health and Social Action Av. 9 de Julio 1925 Phone: 5-41-345-3612/3641 Fax: same as telephone Environmental Category C Date this PID Prepared September, 1999 Appraisal Date February 8, 1999 Project Board Date October 14, 1999 1. Country and Sector Background: Background. Total health care spending in Argentina has long been one of the highest in Latin America, about eight percent of GDP. The overall health indicators of Argentina are good when compared with those of other countries in the region, and have improved markedly over the past ten years. In 1995, life expectancy stood at 73 years, 12 more than 1960, and in 1997 the crude death rate stood at 7.6 per 1,000. In 1997, infant mortality stood at 18.8 per 1000 births, and the maternal mortality ratio at 3.8 per 10,000 births, down by 26 and 27 percent from 1990, respectively. These favorable trends suggest that the present maternal and child health strategy and programs should be pursued further. The relatively good national health indicators hide significant variations between the provinces and the different income groups. The poor have much worse health status than the rich, and have a different pattern of death, disease and disability. Thus, despite the recent advances, Argentina's performance, in terms of health indicators and public satisfaction with quality of health care, still can be improved. The roots of this discrepancy lie in the fact that Argentina is a federal state, with significant differences among the provinces in terms of efficiency in health care finance and delivery. To address this problem, the Government of Argentina (GoA) began to implement, in the early 90's, a series of sweeping and promising reforms, which address some of the key issues in the sector. Specifically, the major health sector issues have been: - Health Status. The decrease of the infant and maternal mortality rates allowed Argentina to meet the targets agreed between UNICEF and its member countries in 1991. The country needs to further strengthen its prevention and control programs with respect to some preventable diseases including tuberculosis, dengue and hospital infections. At the same time, Argentina has emerging health problems which include cardiovascular disease, cancers, and injuries which need to be addressed in a more systematic fashion. - Surveillance Capacity. Significant effort has been made in recent years to strengthen the national surveillance system, which tripled the number of communicable disease notifications. In spite of such effort, the system is still under development and needs significant investments in training of its personnel, physical infrastructure and organization. The system needs better coordination at the national level, as well as improvements in standardization, links between epidemiological and laboratory data, and the data telecommunication system. - Health Promotion. Health promotion, as a strategic component of the health system and as a tool for policy development, has just been introduced in Argentina. Historically, health promotion has not been adequately prioritized and the present challenge is to provide effective leadership, policies, and strategies. This is the case in the area of communicable diseases as well as diseases which are the result of life-style choices, such as smoking, poor diet, and alcohol abuse. Other problems, such as the high incidence of traffic accidents which places a significant cost on the health care system and the need to prevent misuse and overuse of drugs, are also not yet part of society's awareness. - Institutional Development. Provincial ministries of health (MoHs) are generally weaker compared to other areas of the Government. Efficiency, regulatory capacity and quality control have started to improve. A National quality control program is in place, with the participation of 214 entities, such as universities, scientific bodies, professional committees and federations. In the early 1990's almost all hospitals were decentralized to the provinces, leaving 5-10 percent of the national health care spending is in the hands of the National Ministry of Health and Social Action (MSAS). The decentralization process has reduced previous inter- province inequities in health care financing, providing more resources to provinces which needed the most. The present challenge is to strengthen the capacity of the National Ministry to fulfill its present role as regulator of the health insurance system, standards and quality assurance of health care delivery, motivator for compensatory programs, and leader in disease control and investigation. - Efficiency. The health system in Argentina needs to improve the management capacity of Ministries of Health, insurance carriers, and public hospitals. Hospital infrastructure needs to be rationalized and rehabilitated, and cost containment mechanisms need to be further developed, especially at the provincial level. The regulation of the private sector, which provides a large part of health care, needs to be updated and enforced. - Equity. More than 30 percent of the population relies entirely on the public health sector. Strengthening the public health services would therefore help to improve the equity of the health system as well as provide these people with improved access and choice of service. The Government's strategy to address these issues, which has been under implementation since the early 1990s with Bank and IDB support, includes initiatives to: - strengthen maternal and child health programs, especially targeted to poor women and children, under on-going Bank-financed Maternal and Child Health and Nutrition Projects I and II; - improve organization, management, and internal efficiency of selected provincial hospitals under the on-going Bank-financed Provincial Health Sector Development Project and IDB-financed operations; - improve and promote the development of primary health care, including the - 2 - development of family medicine training and professional track (i.e. through an I.D.B. financed project); - restructure, improve equity and open competition in the mandatory union- managed health insurance providers and improve the services provided to elderly, retired members under the recently completed Bank-financed Health Insurance Reform Adjustment Loan; - improve regulation of both the union-run health insurers and the private health sector under the Health Insurance Reform operation and its accompanying Health Insurance Technical Assistance Project; - improve the delivery of public health services, introduction of new provider payment systems incentives, and improvement of cost-recovery in public hospitals in selected provinces under the on-going Bank-financed Provincial Reform Adjustment Loans, which are to be extended to other provinces under proposed additional provincial reform operations; - introduce health insurance for the poor, under the proposed Health Insurance for the Poor Project Learning and Innovation Loan (LIL); - control selected infectious diseases, notably HIV/AIDS and sexually transmitted diseases, under the on-going Bank-financed AIDS and STD Control Project, prevent the misuse of drugs under a recently approved LIL, and control other diseases under the proposed Public Health Surveillance and Disease Control Project; and - strengthen public health policy and programs, especially the National Public Health Surveillance System which is to be supported under the proposed project. 2. Project Objectives The objective of the project is to strengthen national, provincial, municipal and local institutions responsible for public health policy and practice. The ultimate goal is to reduce the disease burden, especially among the poor who suffer from a high incidence of preventable disease. It will focus on three areas: public health surveillance , disease prevention and control, and health promotion. First, by strengthening disease surveillance, the project will improve the capacity of the Ministry of Health and Social Action (MSAS) to make informed decisions about prevention and control priorities and to monitor the impact of interventions. Second, the project will strengthen provincial capacity to carry out disease monitoring, control and prevention for several diseases that pose a serious public health threat including tuberculosis, dengue and hospital infections. Third, the project will help to develop a health promotion program focusing on education, social mobilization, and advocacy. 3. Rationale for Bank's Involvement While the Bank has little prior experience with free-standing projects to strengthen national surveillance systems, it does have considerable experience, in many countries, financing a variety of communicable disease projects. Most of these have included support for strengthening specific surveillance activities (examples in LAC include projects in endemic disease control and AIDS/STD control in Venezuela, Argentina and Brazil). The Bank supports other projects, such as the health Sector Reform Project in Egypt and the VIGISUS Project in Brazil, which include health surveillance activities. Complementing this is the Bank's ability to tap international experience. The Bank has an ongoing partnership with the U.S. Centers for Disease Control - 3 - (CDC) and WHO/PAHO, which have often provided technical support in the preparation and appraisal of Bank-financed health projects and contributed to this proposed project. We can also establish within Argentina the complementarity needed between reforms in areas of health service delivery and financing, being supported by other Bank-financed projects, with a focus on public health policy and practice. The Bank has been effective in Argentina in developing capacity for monitoring and evaluation, targeting the poor, and involving local community groups. This has proven to be particularly useful in other social sector programs, notably the Participatory Social Investment Fund (FOPAR), the system for the evaluation of social programs (SIEMPRO), the temporary public works employment program (TRABAJAR), the AIDS and STD Control Project, and the recently approved Drug Prevention LIL. Finally, the Bank can use its knowledge base and established contacts with the provinces, built up over the years under operations such as Provincial Development I and II Projects and the Provincial Reform Adjustment operations, to facilitate implementation and coordination at the provincial level. 4. Project Description Component I: Strengthening the Public Health Surveillance System. This component, to be implemented nationally and in stages, seeks to strengthen the institutional capacity of the MSAS to make informed decisions about prevention and control priorities, to better monitor the impact of interventions and changes in health trends, and allocate resources more effectively. Specifically, it will: (i) review the norms and procedures for surveillance and attempt to standardize case definitions, reporting procedures and data collection in accordance with the new system design; (ii) strengthen human resource capacity at all levels to carry out health surveillance activities in areas of training including the surveillance of selected communicable diseases, chronic diseases, behavioral risk factors and injuries (see Annex 14); (iii) rehabilitate, expand and upgrade the existing national laboratory network (one laboratory level III, 36 laboratories level II, and 25 level I) through the provision of technical assistance, the acquisition of equipment and construction of civil works (See Annex 12) ; (iv) improve quality of the existing health data telecommunications through provision of appropriate hardware, software, communications equipment and the development of an internet-based network for data transfer and storage among the federal, provincial and local levels of the public health system, as well as training and technical assistance to the specialized staff in the laboratory network and health facilities participating in the surveillance system (see Annexes 2 and 13) and the establishment of linkages with other relevant health data; (v) implementation of alternative surveillance methods for specific diseases including a system of surveillance and control of non-communicable diseases through the provision of technical assistance and training for MSAS staff in, inter alia, the design of data collection instruments, questionnaires, scales, sampling methods, record-keeping, and data - 4 - analysis and collection, and collection of base-line data on risk factors and behavior (see Annex 2, Tables A and B); (vi) evaluation that assesses the capacity of the surveillance system to monitor each health event, taking into consideration sensitivity , specificity , efficiency, representativeness, timeliness and flexibility of the system, as well as opportunities for cost-recovery as appropriate and feasible (to be completed and submitted to the Bank by January 31, 2003); (vii) finance an operational research grant program for eligible biomedical research bodies to carry out research in epidemiological surveillance and disease control; and (viii) evaluate effectiveness and relevance of training activities supported by the project. Component II: Strengthening Disease Control. This component will strengthen the institutional capacity of participating provinces and the City of Buenos Aires to carry out disease monitoring, control and prevention. Specifically, it will support: (i) tuberculosis control in 10 provinces in the poorest northeast and northwest of the country, Metropolitan Buenos Aires, and the areas of highest incidence and multi-resistance to therapy; (ii) dengue control in high risk populations located in the poor provinces such as, Jujuy, Catamarca, Tucuman, Salta, among others, through 52 sentinel sites (selected on the basis of risk mapping, prevalence, vectors density, and population) which will monitor febrile illness including lab testing of suspected cases, (see Annex 2, Table D) and vector monitoring in areas of high risk with high levels of vector infestation; (iii) nosocomial (hospital acquired) infection control in 100 randomly selected hospitals (80 public and 20 private) throughout the country, which meet specific selection criteria (see Annex 2, Table E). This will include support for: a) elaboration of the norms and procedures for NI control; b) existing infrastructure rehabilitation; c) collection of baseline data on hospital infections; d) training of professional teams for prevention and control of selected diseases; e) computers and software for surveillance; f) supervision and technical assistance; and h) vehicles ; and (iv) control of emergent and re-emergent diseases which may occur during the life of the project, through grants to eligible agencies. Criteria are defined in the Operational Manual. Component III. Health Promotion (HP) . This component will strengthen MSAS capacity to carry out a health promotion strategy through education, social mobilization and policy advocacy. Specifically, it will support : (i) strengthening the institutional capacity of the health promotion unit of the MSAS, through training, equipment and rehabilitation of existing infrastructure; (ii) training of MSAS and HP personnel in media and communications, and training of health journalists in the areas of disease surveillance and control; (iii) eligible subprojects for local institutions and community groups to set up or strengthen disease prevention and health promotion within their communities (eligibility criteria and application procedures are - 5 - described in the Operational Manual); (iv) dissemination of project objectives and activities through regular newsletters directed at the public health community and through workshops, conferences and technical meetings for stakeholders such as politicians, government officials, the medical and private insurance community and others; (v) over the life of the project, meetings at least on a quarterly basis with a committee of political and social leaders, including health journalists, to define a strategy and action plan to help ensure sustainability of the project; (vi) a media campaign against tobacco addiction to be designed and implemented on the basis of a risk factors survey; and (vii) implementation of a plan to include private corporations in a partnership with the MSAS to combat tobacco addiction in the employees of such corporations. Component IV: Project Administration. The project will help finance the administrative and operating costs of the Project Coordinating Unit (PCU) over a four year period. This includes: (i) salaries for PCU technical and managerial staff, excluding the remuneration of the core technical team within MSAS; (ii) domestic and international travel and per diem for PCU staff; (iii) training of PCU staff; and (iv) equipment, materials and office supplies. 5. Project Financing Project costs are estimated at US$75 million. Bank financing would be for US$52.5 million , the central government and co-financiers would finance US$22.5 million. 6. Project Implementation This is a four-year project. The planned effectiveness date is January 31, 2000 with a closing date of Aril 30, 2004. The executing agency will be the Ministry of Health and Social Action. 7. Project Sustainability As explained earlier, Argentina needs to make an expanded investment in public health programs, like the one being supported under the proposed project. Better surveillance will correct for underreporting of diseases and may therefore increase health care costs in the short to medium term. In the long run, the recurrent costs are expected to stabilize and/or decrease if only because epidemics are contained earlier. While the economic and social benefits of such an increase in investment are clear, the decision to shift public resources - especially during times of economic recession - are not easy for policy makers given the competing demands for reduced resources. An on-going public expenditure review being conducted by the Government, with Bank-financed technical assistance, should help to lay the ground for this and other public programs. The burden of recurrent spending generated by the proposed project on total public health spending is in relative terms modest and under normal circumstances should be feasible within expected resource envelopes available to the health sector. The recurrent expenditures are expected to rise from about $400,000 in the first year of the project to about $3.3 million upon project completion. Nevertheless, the prevailing financial crisis introduces - 6 - an important element of uncertainty into growth projections for Argentina, and consequently into those of public finance. Present estimates of the prospects for the health budget indicate that funds will be available to meet the incremental, non-Bank financed, recurrent costs generated by the project. However, sheer availability is no guarantee that these funds will effectively be made available for the activities generated by the project. The issue of additional recurrent costs and their adequate financing by the GoA therefore needs to be closely monitored, especially towards the end of and after the project implementation period. In the case of more acute financial difficulties in the future, the project will review the implementation plan, and make appropriate adjustments to focus on priority activities. With a view to ensuring the long-run sustainability of the system and its enhancement over time, the project will also support promotion of the financial involvement of the private sector and if successful these initiatives could help to reduce the incremental financial burden on the public sector. To reinforce sustainability, stakeholders were involved in project preparation and were part of the system assessment and decision-making process. An external advisory board for the project (comprised of public health academicians and practitioners, provincial public health specialists, government officials, representatives from Agriculture, Finance, Tourism and other social sectors, and representatives of professional organizations) will advise on all three project components and may be helpful in advocacy. Support for technical assistance in operations and maintenance will be included under the project to help provinces and municipalities ensure sustainability of subprojects. The management and monitoring capacity of provinces and municipalities will be strengthened. Surveillance capacity will be strengthened at all three levels of the system, through extensive training, upgrading of facilities, provision of equipment and establishing a data management communication system. New personnel will also be contracted. 8. Lessons Learned from Past Operations in the Country/Sector The Bank has not yet gained any specific lessons from similar Bank-financed experiences, since this is only the second project of its kind in the Bank, the first being the Brazil VIGISUS Project (Ln. 4394-BR). However, some lessons from related projects may be applied to this project: - Brazil: Amazon Basin Malaria Control (PCMAM) and Northeast Endemic Disease Control (PCDEN) Projects. The ICRs for these projects suggest that disease control projects should: (i) consider defining broader objectives, e.g. combining support for malaria control with control of other communicable diseases; (ii) include demand-driven components to finance state and municipal communicable disease control subprojects; and (iii) provide technical assistance to strengthen the capacity of weaker states and municipalities. PCMAM and PCDEN also taught us that training and other forms of institutional strengthening should be implemented at least at the same pace as investments in civil works and equipment. This has been taken into account in the project design. - Peru: The Social Development and Compensation Fund Project (FONCODES). - 7 - Some relevant lessons from this project include: (i) independent ex-post evaluation of samples of completed subprojects were valuable in assessing performance and impact; (ii) educating beneficiaries concerning their role in the project and the use of services offered by the project should be emphasized; (iii) training in the operation and maintenance of completed projects should be systematized; and (iv) selecting appropriate performance indicators at the outset of the project, with an adequate monitoring and evaluation system is important. - Argentina: Maternal and Child Health and Nutrition I and II (PROMIN). These projects have been successful in reaching poor communities and involving them despite varying levels of institutional capacity. In the two projects, provinces manage subprojects at the municipal level through provincial implementation units while an overall project coordinating unit (PCU) at the central level coordinates project implementation. While the proposed project does not have decentralized execution such as PROMIN, the central PCU will be assisted by a high level technician, who will coordinate project implementation at the provincial level. The PROMIN experience demonstrates that not every municipality can be expected to have the capacity to prepare subprojects effectively. The proposed project will therefore provide technical assistance to weaker municipalities through the PCU, when necessary. Lessons from international experience have also been tapped for this project: - Institutions in other sectors, such as the Ministry of Agriculture, Ministry of Tourism, Ministry of Finance and others should be actively involved in strengthening the surveillance system. Extensive project promotion was carried out during preparation and a project steering committee, with representatives from these and other ministries, has been suggested by the Bank as a way of ensuring continuing inter-ministerial cooperation. - International experience has shown that early involvement of senior officials from the MSAS ensures national ownership of the national surveillance system. In the preparation of the proposed project, the National Epidemiology Unit, the provincial epidemiologists and health officials and the National Commission of Epidemiology were all involved in the assessment of the current surveillance system. It has been agreed that formal assessments will be carried out on a regular basis involving the MoHs and international partners. - A review of international experience in surveillance shows that surveillance systems are often overly ambitious, unrealistic and beyond local capacity. Often, too many diseases are included and institutions are subsequently overloaded with responsibilities that cannot be fulfilled. For the proposed project, an economic analysis was carried out to help establish surveillance priorities and appropriate methods, which found that the current system covers an impractical 50 conditions. Of these, 29 were selected for surveillance based on their epidemiological significance and relative cost-effectiveness of intervention. Four of the 29 were selected for surveillance by alternative methods, such as sentinel surveillance. The remainder will use traditional surveillance methods (notifiable conditions). -8- 9. Program of Targeted Intervention (PTI): Since the project targets diseases that disproportionately affect the poor, it will contribute to poverty alleviation and enhance social development. 10. Environmental Aspects The project would have a positive environmental impact by specifically addressing the issue of safe handling of insecticides and laboratory and medical materials and waste, including the development of an effective biosafety program. Beneficiaries would have to present adequate environmental and safety plans addressing such issues as: handling the products listed above, storage facilities for hazardous materials, transportation and disposal, and training of personnel on environmental and safety issues. Training in the proper handling and disposal of hazardous materials and waste would be provided through the project. 11. Program Objective Categories The primary categories are physical investment and institutional building. Contact Points Dr. Horacio Lopez, Coordinator Anabela Abreu, Task Manager Ministry of Health & Social Action Human and Social Development Group Avenida de Mayo 953, 3 piso The World Bank Buenos Aires, Argentina 1850 I Street NW, "I Building" Phone: 5-41-345-3612/3641 I 7-187 Fax: same as phone Washington, D.C. 20433 Phone: 202-458-7763 Fax: 202-522-3135 The InfoShop The World Bank 1818 H Street, N.W. Washington, D.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500 Note: This is information on an evolving project. Certain activities and/or components may not be included in the final project. Processed by the InfoShop week ending October 1, 1999. - 9 - ANNEX Because this is a Category B project, it may be required that the borrower prepare a separate EA report. If a separate EA report is required, once it is prepared and submitted to the Bank, in accordance with OP 4.01, Environmental Assessment, it will be filed as an annex to the Public Information Document (PID). If no separate EA report is required, the PID will not contain an EA annex; the findings and recommendations of the EA will be reflected in the body of the PID. Surveillance is the ongoing systematic collection, collation, analysis, and interpretation of health data, closely integrated with the timely dissemination of these data, to those who need to know in order that action may be taken. The tasks of public health surveillance include detecting new health problems, detecting epidemics, documenting the spread of disease, providing quantitative estimates of the magnitude of morbidity and mortality, identifying potential factors involved in the disease occurrence, facilitating epidemiological and laboratory research, and assessing control and prevention activities. Summarizing, surveillance is a key tool for epidemic response, control activities, health policy and resource allocation. Biosafety level 1 = basic level of containment, appropriate for handling microorganisms that represent little or no risk to humans, animals or the environment; Biosafety level 2 = routine work on human pathogens not thought to be transmitted by the aerosol route. Basic physical precautions include limited access to the laboratory, biohazard signs posted outside the lab, biosafety manual defining any needed waste decontamination or medical surveillance policies, and a biological safety cabinet for use whenever agents that may splash or cause aerosols are handled. Biosafety level 3 = specialized laboratories which allow workers to safely handle more dangerous pathogens. They require all the conditions for Biosafety level 2, as well as controlled access to the laboratory. Special equipment and procedures to decontaminate all waste, wearing of special clothing, among others. All work with infectious material is done under a biological safety cabinet, and all waste is disinfected prior to leaving the lab, usually by an autoclave. Sensitivity is the proportion of persons with a disease/health event that are detected by the surveillance system. Specificity is the proportion of persons without a disease/health event that are detected by the surveillance system. - 10 -