Argentina - Maternal and Child Health and Nutrition II (PROMIN II)

Report No. PIC4767 Project Name Argentina-Maternal and Child Health and (@+) Nutrition II (PROMIN II) Region Latin America and Caribbean Sector Health Project ID ARPE6059 Borrower Argentine Republic Implementing Agency Ministry of Health Date this PID Prepared February, 1997 Appraisal Date February 12, 1997 Expected Board Date May 15, 1997 1. Country and Sector Background In many respects, Argentina already possesses a highly developed health system, particularly by developing country standards. The country has one of the highest doctor-to-population ratios in Latin America (nearly three doctors per thousand inhabitants), while the number of hospital beds (4.5 per thousand inhabitants) is similar to that of many OECD countries. As in most middle-income countries, Argentina shows two coexisting epidemiological profiles: (i) a high incidence of non- communicable and degenerative diseases (including cardiovascular diseases, cancer, and diabetes), and a rapid increase in accidents, corresponding to the profile of industrial countries; and (ii), a high incidence of infectious and parasitic diseases, reflecting conditions usually prevailing in developing countries. Despite its achievements, the health system still faces significant problems. The infant mortality rate (IMR) of 22 per 1000 live births is higher than in Chile, Colombia, Costa Rica, and Uruguay which have lower per-capita incomes and spend less on health. There are major variations in the IMR across regions: the IMR is 1.1-1.3 times higher in the large, poor, periurban areas than the national average. Three-fourths of neonatal deaths and 60 percent of post-neonatal deaths are concentrated among the poor. Neonatal deaths result from poor-quality obstetric care and maternal undernutrition. Post-neonatal deaths are caused by immunopreventable and acute respiratory diseases. They could be prevented through opportune health care interventions and better nutrition. The same applies to mortality for children aged 1-4 and maternal mortality, where two-thirds of deaths could be prevented by opportune, good quality care. At present, prenatal care coverage remains low. Health care has deteriorated over the last two decades. With the exception of incipient progress in the areas covered by PROMIN I (Loan 3643-AR), public services are overburdened and poorly equipped to handle the volume of demand, especially in the poor provinces of the North and Northwest, and in densely populated periurban areas. In some areas, there is increasing pressure on health services resulting from immigrants in provinces bordering  Paraguay, Bolivia, and Chile. Lack of priorities, operating standards, incentives, and accountability affect most provincial services. Poorly trained and utilized health personnel are major causes of inefficiency. As a result of economic recession and unemployment, many families have lost their social benefits and have to be assisted by the public sector. Mothers and children have suffered the effects of the economic crisis more than other members of poor households. This is because: (i) poor households contain on average more than twice as many children as other households; and (ii) undernourishment tends to affect mothers and children disproportionately. The number of pre-school-age children with unsatisfied basic needs (related to housing, hygiene, access to safe water, and health care) is estimated at 1.5 million. Of these, about one-third receive nutrition supplementation through provincial and municipal kindergartens, mothers' clubs, and other public and private channels. Even this limited assistance is often not well planned or supervised. The widely differing organizational arrangements and jurisdictions responsible for this age group in provinces and municipalities, together with small private sector participation, hinder efforts to rationalize and expand services. With the exception of those who have started to be covered by PROMIN I, very few preschoolers from poor families receive psycho-social stimulation. This makes entry in schools more difficult and increases the rates of repetition and dropouts. As described in its policy letter of March 26, 1996 (linked to the Health Insurance Reform project), the Government's general objectives for the health sector are to: (i) ensure full exercise of the population's right to health care; (ii) improve the accessibility, efficiency and quality of medical attention; (iii) reduce avoidable morbidity and mortality risks; (iv) rethink and redirect the role of the State in the health sector. To reach those objectives, the following sector strategies have been defined: (i) give priority to mother and infant care; (ii) modernize the public hospital system; and (iii) improve the financing of the system. Nutrition Issues. Information about nutrition status in Argentina is not up to date. The MOH has estimated that, by the mid-1990s, 25 percent of children under 5 years of age were below the tenth percentile in terms of height-for-age. A household survey performed by the National Institute for Statistics and Census (INDEC) during 1995 shows that in the Greater Buenos Aires area 17 percent of children of poor households were below the tenth percentile in terms of height-for-age. In the early 1990s, a small sample survey of pregnant women in a poor area of the province of Buenos Aires indicated that in the first and second trimesters of pregnancy about 20 percent of the women were underweight, and at the third trimester about 30 percent, according to weight/height criteria. Under PROMIN I, a National Nutrition Survey will be undertaken. The survey is currently being bid and the contract is expected to be signed in February 1997. Field work would be completed in June 1998 - 2 -  and preliminary results would then be available. In 1995, the Government created a Central Unit to Analyze and Plan Food and Nutrition Policies (UCAPPAN) within the Secretariat of Social Development (SDS). This institution is receiving technical assistance from IDB. There are currently nine nutrition programs costing US$332 million per year(see 1/) . Two of these programs (Milk for pregnant women and malnourished infants - "Dacion de Leche"; and PROMIN) come under the MOH. The seven other programs depend on SDS and are by far the largest, representing 90 percent of total funds. These programs do cover the most vulnerable groups in Argentina: pregnant and lactating women, infants, and young children, and the elderly. They are implemented in a decentralized way in the provinces and food is purchased locally. However, they do face significant implementation problems: (i) there is a lack of clear targeting criteria; (ii) there is an absence of monitoring indicators and program evaluation; and (iii) there is a lack of regularity in the transfer of funds to the provinces. 2. Project Objectives The project would help extend the coverage of the PROMIN program. The project would help the Government: (i) increase coverage of maternal and prenatal care services; (ii) improve pediatric coverage of children aged 0-6; (iii) increase coverage of early childhood development programs and; (iv) decentralize and strengthen social service management. 3. Project Description The project, whose total cost is estimated at US$171 million, would be implemented over a five-year period starting in 1997 and would have three components. The Bank would finance activities in each component, as would the IDB and the provinces and municipalities. These components include: (a) Maternal and Child Health and Nutrition. This component would cover (i) women's reproductive and child health care; (ii) food supplementation for undernourished pregnant women and children under 6 years of age, as well as for lactating mothers; and (iii) health and nutrition education and promotions, and environmental health. (b) Strengthening of MOH's Statistical System. This will help improve the statistical system through the financing of improvement in system design, computer hardware and software, and training of personnel at the provincial and central level. (c) Project Administration. This component would help finance the administrative and operating costs of the PCU over a six or seven- year period (1997-2003). This includes: (i) financing of PCU consultants; (ii) PROMIN II project preparation costs; (iii) travel; (iv) training; and (v) other administrative expenses (materials, cleaning, etc.). 4. Project Financing Project costs are estimated at US$171 million. Bank financing will cover US$100 million; the IDB would finance US$53.9 million; and provinces and municipalities would contribute the remaining US$17.1 million. 5. Project Implementation The executing agency will be the Ministry - 3 -  of Health. 6. Project Sustainability Analysis of project sustainability will be completed during project appraisal. Incremental recurrent expenditures would be incurred to provide health facilities and child development centers with the necessary inputs in personnel as well as goods and materials. The hiring of additional staff, when redeployment of personnel is not feasible, and the development of support services would be based on a gradual phase-in of project activities. Provincial and municipal incremental recurrent expenditures would be financed by the federal government on a declining basis. Specifically, incremental recurrent purchases of food, drugs, and other materials, and incremental recurrent salaries, would be financed as follows: 100 percent, 70 percent, and 30 percent during the first, second, and third years of implementation by the federal government, and the balance, as well as all incremental costs beginning in year four, out of provincial and municipal budgets. This would be specified in the subsidiary agreements between the MOH and the provinces. 7. Lessons Learned from Past Operations in the Country/Sector In addition to the analysis of PROMIN I, a review was made of lessons learned from other relevant Bank group projects in health and nutrition. The problems most encountered include: (i) uncertain Government commitment; (ii) lack of flexibility in design; (iii) inadequate project implementation arrangements; (iv) lack of clear performance indicators; and (v) excessive number of covenants. Government Commitment. Numerous projects have experienced problems in implementation because of lack of commitment, insufficient capacity in the ministries, or both. Flexibility and Simple Design. Successful projects have been marked by simplicity, clarity, and flexibility in design that would allow a project to adapt itself easily to changing circumstances. Project Implementation Arrangements. Project implementation needs effective and sustainable institutional arrangements. Project management unit functions should not be assumed by the Government line agencies without adequate preparation. Performance Monitoring Indicators. Past projects have suffered from the lack of explicit measurable progress and end- result indicators. The proposed project will include progress, implementation, and impact indicators, that will be monitored throughout project implementation. Number of Covenants. The number of covenants should be limited and monitorable. Compliance should be reviewed regularly during supervision and enforced when necessary. The project will be designed accordingly. 8. Poverty Category N/A 9. Environmental Aspects. The proposed project has an environmental rating of B. Please see Annex below. - 4-  10. Program Objective Categories The primary category is Public Sector Management (PB). 1/ based on "Programas Alimentario-Nutricionales en Argentina", Fernando Vio, May 13 1995 (report to the IDB) Contact Point: Public Information Center The World Bank 1818 H Street N.W. Washington, D.C. 20433 Telephone No.: (202) 458-5454 Fax No.: (202) 522-1500 Note: This is information on an evolving project. Certain components may not necessarily be included in the final project. Processed by the Public Information Center week ending April 25, 1997. - 5 -  ANNEX Environmental Aspects The infrastructure and equipment components include an analysis of environmental health as part of the formulation and evaluation of the subprojects (principally treatment and disposal of solid and liquid waste). A guide for the formulation and evaluation of environmental aspects with sections on diagnosis, interpretation and prevention of situations forms part of the Operational Manual. For the purpose of controlling and preventing any particular situation, subprojects will include an action plan for measures to be taken to dispose, and treat appropriately, the wastes of the health centers, regional health centers (CRRs), hospitals and early childhood development centers (CDCs). The proposed project has an environmental rating of "B." -6-