Argentina - Maternal & Child Hlth & Nutrition (PROMIN)

 ICRR 10838 Report Number : ICRR10838 ICR Review Operations Evaluation Department 1. Project Data: Date Posted : 03/16/2001 PROJ ID : P006025 Appraisal Actual Project Name : Ar-maternal & Child Hlth & Project Costs 160 134 Nutrition (PROMIN) US$M ) (US$M) Country : Argentina Loan /Credit (US$M) Loan/ US$M ) 100 100 Sector (s): Primary Health Including Cofinancing Reproductive Health Chi US$M ) (US$M) L/C Number : L3643 Board Approval 94 FY ) (FY) Partners involved : UNICEF Closing Date 12/31/2000 03/30/2000 Prepared by : Reviewed by : Group Manager : Group : 2. Project Objectives and Components a. Objectives (i) To support the GOA and strengthening maternal and child health and nutrition, as well as early child development; (ii) improve the organizations involved in the delivery of these programs; and (iii) strengthen decentralization of decision -making and management in the participating provinces and municipalities . b. Components (i) maternal and child health and nutrition; (ii) early childhood development component; (iii) institutional strengthening c. Comments on Project Cost, Financing and Dates The Bank loan was fully disbursed, but the financial crisis in 1997/8 contributed to shortfalls in anticipated counterpart financing -- $34 million instead of $60 million at appraisal. 3. Achievement of Relevant Objectives: The project contributed to improvements in infrastructure and in the operation of health and child development services in disadvantaged urban areas, and to greater attention to maternal and child health /nutrition and child development in target provinces . The project met or exceeded most of its physical and training objectives . Under component (i), 195 health centers and 8 maternity wards were rehabilitated, and 75 health centers built, and over 1900 health care providers received MCH training . Under component (ii), the project constructed 153 Child Development Centers, most in poor neighborhoods, and 1739 child development workers received training . The project was less successful, however, in achieving its institutional and policy objectives . All the originally-planned sector studies were dropped, and the resources reallocated to infrastructure . A number of intermediate health service indicators improved in target areas, but an ex -post analysis found no impact of project interventions on health or nutrition status. The PROMIN II project further expanded the PROMIN I model to additional provinces, and is attempting to address sustainability concerns . 4. Significant Outcomes/Impacts: The pilot introduced a new model for maternal and child health (MCH) service delivery (originally designed by UNICEF), which contributed to improvements in health service process indicators in target areas and clinics -- including improved treatment protocols, reduced waiting time, and improved referral practices . MCH health service indicators improved in target areas -- for example, in Mendoza, obstetric coverage increased from 15 to 58 percent, and pediatric coverage increased from 23 to 55 percent. Geographical targeting meant that the poor benefited disproportionately from both health and ECD project investments. Requirements for sub-project design contributed to information -based planning and monitoring of health and child development investments . Tools such as supply and demand analysis, including beneficiary surveys, were introduced to local authorities by the project . 5. Significant Shortcomings (including non-compliance with safeguard policies): Despite infrastructure and training improvements, the project made relatively little contribution to changing health sector policies or provider incentives -- e.g., for outreach services. The impact on actual provider behavior may therefore be limited. Due to lingering effects of the 1997/98 financial crisis and inadequate planning for recurrent costs at province  and municipal levels, project investments risk not being sustained, particularly for the ECD component . The early child development component had several design flaws, including inadequate assessment of demand by parents for government child development centers; insufficient assessment of the actual extent of child malnutrition; lack of attention to the need for an institutional "home" for the component (it fell between the health and education sectors ); and insufficient planning for sustaining the centers after project close . Coordination between the ECD centers and clinics was weak . Monitoring and evaluation figure prominently in project design, but implementation fell short . Baseline data were not collected, making it more difficult to assess impact, or provide country stakeholders with evidence of the strengths and weaknesses of the approaches piloted by the project . 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Satisfactory Moderately Satisfactory Contributions in infrastructure and training were significant, but sustainability is a major concern, particularly for the ECD component. The borrower's comment also endorse a "moderately satisfactory" overall rating. Institutional Dev .: Modest Modest Sustainability : Unlikely Unlikely Shortfalls in recurrent financing represent a risk to health investment, and local governments show limited commitment to sustaining the child development centers . Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Exemplary NOTE: NOTE ICR rating values flagged with ' * ' don't comply with OP/BP 13.55, but are listed for completeness. 7. Lessons of Broad Applicability: The ICR includes a number of relevant lessons, including : Financial sustainability is the lynchpin --- benefits of the project are jeopardized by the inadequate assessment of municipal and provincial willingness to take responsibility for PROMIN interventions Visible investments are not enough -- investments in facilities, training, and equipment were important, but were not sufficient to bring about change in the culture of health care provision . Demand-driven projects can lead to unexpected results -- demand from provinces for construction of ECD centers far out stripped original expectations, but this was not accompanied by willingness to sustain recurrent expenditures. Monitoring and evaluation need special attention -- project plans for extensive M&E gave way to a focus on investments. This meant there is little evidence to demonstrate the strengths or weaknesses of the PROMIN model, diminishing its "spinoff" influence outside the project areas . Parallel executing structures can impede institutional sustainability -- the use of project implementation units at national and provincial level contributed to excellent implementation, but created difficulties for long -term ownership. Finally, it is striking that although the project contributed to improvements in MCH service delivery, no impact could be discerned on health outcomes -- perhaps because of limited progress in outreach services, or the predominance of non-health service factors in determining many health outcomes . This raises an interesting question -- if the Bank were to undertake more regular and in depth impact assessments, might this lead to fundamental rethinking in the Bank's approach to health sector investments and reforms? 8. Assessment Recommended? Yes No 9. Comments on Quality of ICR: This intensive learning ICR provides a frank assessment of the project's strengths and weaknesses . It incorporates findings from a stakeholder workshop, beneficiary surveys, and an impact evaluation (albeit a limited one, due to insufficient baseline data).