Argentina - Maternal and Child Health and Nutrition Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No: 20905 IMPLEMENTATION COMPLETION REPORT (36430; 3643A; 3643S) ON A LOAN IN THE AMOUNT OF US$100.0 MILLION TO THE ARGENTINE REPUBLIC FOR A MATERNAL AND CHILD HEALTH AND NUTRITION PROJECT September 29, 2000 Country Management Unit for Argentina, Chile and Uruguay Human Development Sector Management Unit This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS (Exchange Rate Effective ) Currency Unit = Argentine Peso (AR$) AR$1.00 = US$ 1.00 US$ 1.00 = AR$1.00 FISCAL YEAR January I through December 31 ABBREVIATIONS AND ACRONYMS CDI Centro de Desarrollo Infantil (Child Development Center) GDP Gross Domestic Product GNP Gross National Product ICR Implementation Completion Report IDB Inter-American Development Bank MCH/N Maternal and Child Health/and Nutrition MoH Ministry of Health MIS Management Information Systems NGO Non-Governmental Organization Obras Sociales Social Health Insurance Funds (linked to workers' place of employment) PCU Project Coordination Unit PROMIN Programa Salud Materno-Infantil y Nutrici6n (Matemal and Child Health and Nutrition Program UCP Unidad de Coordinaci6n del Proyecto (Project Coordination Unit) UEP Unidad Ejecutora Provincial (Provincial Executing Unit) UEM Unidad Ejecutora Municipal (Municipal Executing Unit) UNDP United Nations Development Program UNICEF United Nations Children's Fund Vice President: David de Ferranti Country Director: Myrna Alexander Sector Director Xavier Coll Task Team Leader Ruth Levine  FOR OFFICLAL USE ONLY Implementation Completion Report Argentina Maternal and Child Health and Nutrition Project CONTENTS Page No. 1. Project Data 1 2. Principal Performance Ratings 1 3. Assessment of Development Objective and Design, and of Quality at Entry I 4. Achievement of Objective and Outputs 5 5. Major Factors Affecting Implementation and Outcome 10 6. Sustainability 11 7. Bank and Borrower Performance 13 8. Lessons Leamed 16 9. Partner Comments 18 10. Additional Information 26 Annex 1. Key Performance Indicators/Log Frame Matrix 27 Annex 2. Project Costs and Financing 29 Annex 3. Economic Costs and Benefits 31 Annex 4. Bank Inputs 32 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 35 Annex 6. Ratings of Bank and Borrower Performance 36 Annex 7. List of Supporting Documents 37 Annex 8. Beneficiary Survey Results 38 Annex 9. Stakeholder Workshop Results 41 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization.   Project ID: P006025 Project Name: MTNAL CHILD HLTH & N Team Leader: Evangeline Javier TL Unit: LCSHD ICR Type: Intensive Learning Model (ILM) o ICR Report Date: September 29, 2000 1. Project Data Name: MTNAL CHILD HLTH & N L/C/TF Number: 36430; 3643A; 3643S Country/Department: ARGENTINA Region: Latin America and Caribbean Region Sector/subsector. HT - Targeted Health KEY DATES Original Revised/Actual PCD: 01/17/92 Effective: 09/30/93 10/27/93 Appraisal: 03/08/93 MTR. 06/05/97 04/15/98 Approval: 08/03/93 Closing: 12/31/2000 03/31/2000 Borrower/lImplementing Agency: Government of Argentina/Ministry of Health Other Partners: STAFF Current At Appraisal Vice President: David De Ferranti Shahid Javed Burki Country Manager: Myma L. Alexander Ping Cheung Loh Sector Manager: Xavier E. Coll Julian F. Schweitzer Team Leader at ICR: Evangeline Javier Jose Andreu ICR Primary Author: Ruth E. Levine 2. Principal Performance Ratings (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HL-Highly Likely, L=Likely, UN=Unlikely, HUN=Highly Unlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible) Outcome: S Sustainability: UN Institutional Development Impact: M Bank Performance: S Borrower Performance: S QAG (if available) ICR Quality at Entry: Project at Risk at Any Time: 3. Assessment of Development Objective and Design, and of Quality at Entry 3.1 Original Objective: The US$100 million PROMIN I investment loan, signed in August 1993, was designed to support the Government of Argentina in strengthening maternal and child health and nutrition, as well as early child development services for poor populations; improving the organizations involved in the delivery of these programs; and strengthening decentralization of decision-making  and management in the participating provinces and municipalities. Under the project, health promotion, disease prevention and child development activities were aimed at reducing infant and maternal mortality and illness, and improving cognitive outcomes among young children in poor urban communities. The project sought to directly benefit approximately 500,000 low-income women and children living in urban areas, representing about 18 percent of the reproductive-age women and children under 6 in households below the poverty line. In the early 1990s, as the first freestanding health and nutrition investment lending operation in Argentina and one of the earliest operations of any kind in the human development sector in the country, PROMIN I responded to both Borrower and Bank demands for attention to the social sectors as a complement to macroeconomic adjustment. Improving health conditions and child development in poor, urban families was considered a key strategy in the effort to reduce disparities in social welfare and intergenerational transmission of poverty in Argentina. The design was prepared primarily by a technical tearn from UNICEF, based on their contemporaneous framework for maternal and child health, nutrition and child development. As part of an effort to support decentralized decision making, the original design took the form of a set of criteria and eligible expenses, under which provinces were to propose subprojects. The design of PROMIN I followed a long-standing pattern of investing in public sector inputs-infrastructure, supplies, training, information systems and others-to achieve improved health and education outcomes. While following the traditional "supply-side" approach, the PROMIN I design incorporated notable innovations: First, combining health and education activities in one operation was a new concept. Second, PROMIN I was geographically targeted to reach women and children in poor neighborhoods, rather than the general population. Third, within Argentina's complex federal structure, it sought to tailor investments to provincial and municipal contexts, leaving substantial room for local adaptations of the PROMIN model. Fourth, it incorporated resources for rigorous monitoring and evaluation, with the aim of generating data for better programmatic decision making. The PROMIN I project included a multitude of specific activities, as described below. However, the original concept of the project can only be understood by viewing those activities as part of a comprehensive package. For PROMIN I to be fully successful, individuals at national, provincial, municipal and point-of-service levels had to act in a synchronized manner, and a significant cultural shift had to occur on the part of both service providers and families. To achieve the anticipated health improvements, the PROMIN model of care, or modelo de atenci6n, required not simply that basic maternal and child health and nutrition (MCHN) services be expanded and improved, but that old ways of doing business be put aside, and that a large and coordinated set of social communication, outreach, education and monitoring activities be put into place. Pregnant women and mothers of young children from poor families had to view health promotion activities available at health centers-for example, prenatal care and well-child care- as valuable and responsive to their needs. To achieve better child development outcomes, the PROMIN concept necessitated that both government institutions and parents accept the idea that the well-being of very young children is enhanced when they are cared for in clean, stimulating, healthful publicly-financed institutions. -2 -  3.2 Revised Objective: Not Applicable 3.3 Original Components: PROMIN I financed activities in three components, as described below (ref Staff Appraisal Report (SAR), pp 23 ff). It was expected that activities would occur. in 16 municipalities in six provinces, using an average of US$16 million per province. The original provinces-Buenos Aires, C6rdoba, Entre Rios, Mendoza, Santa Fe and Tucuman-were not characterized by high levels of poverty, but rather by large urban populations and therefore the potential to reach many poor neighborhoods. At the time of appraisal, the Florencio Varela subproject in the Province of Buenos Aires had been designed in detail as a model. The other subprojects were to be designed during implementation, and were to meet certain criteria established in the SAR, including: a minimum of 30 percent of the population below the poverty line ("unsatisfied basic needs"); fiscal and administrative capacity; political commitment; and willingness to sign an agreement with the Ministry of Health regarding project execution and incremental transfer of financial responsibilities to local sources. Because the subprojects were not designed at the start of the program, neither specific funding amounts nor quantitative targets were assigned to the separate components. Rather, approximately US$123 million were to be devoted to the subprojects (or 77 percent of the total US$160 million (US$100 million loan plus US$60 million counterpart) operation); approximately US$17 million (or 1 percent) of the project was to be dedicated to institutional strengthening, in the form of studies, social communication and technical assistance; and the remaining resources were to be devoted to administration and contingencies. Component 1: Maternal and Child Health and Nutrition. The operation financed expansion, refurbishing, equipping and/or re-equipping of existing health facilities; hiring additional health and management staff, generic drugs and supplies; and food supplements. While seeking to make the health center the main locus of service delivery for basic MCH/N services, this component also supported the expansion and improvement of maternity wards in overcrowded urban public hospitals, and the establishment of a functioning referral system for high-risk pregnancies and complicated deliveries. These inputs were intended to support delivery of a basic package of services consisting of (a) women's reproductive and child health care; (b) food supplementation for undemourished pregnant and lactating women and children under 6 years of age; and (c) health and nutrition education and promotion. Component 2: Early Childhood Development Component. PROMIN I intended to transform existing feeding programs for children (comedores infantiles) and kindergartens into child development centers (Centros de Desarrollo Infantil, or CDI) in which children ages 2-5 in urban slum areas would benefit from exposure to educational materials, toys, and the attention of trained early childhood educators and volunteers (Community Education Promoters, or Promotoras), as - 3 -  well as from food supplementation. It was anticipated that there would be coordination between Components 1 and 2, so that all children participating in CDIs would also benefit from growth monitoring, and from high quality well- and sick-child care in PROMIN-supported health centers in their neighborhoods. Component 3: Institutional Strengthening. This component covered a wide range of activities at municipal, provincial and national levels, including training, information systems, social communication, technical assistance for reorganizing school feeding programs, and studies. All of these were intended to support either direct service delivery or coordination at each of the three relevant administrative and political levels. 3.4 Revised Components: The components were not formally revised during the execution of the operation. However, changes were introduced in the geographic scope, scale of the subprojects and content of the interventions. Specifically, in 1995, 7 additional provinces were given financial support, and a new type of activity called "expanded technical assistance projects" were offered to provinces that did not meet the original eligibility criteria. The expansion in geographic coverage resulted in a decrease in the size of subprojects, relative to what had originally be anticipated (from an average of US$16 million per subproject to $6.6 million approved and $4 million executed). During that period, in response to increased demand and based on a generally positive sense of the implementation of PROMIN I, a new $100 million loan, PROMIN II, was developed to expand the PROMIN model. PROMIN II was approved in 1995. PROMIN II was designed before many PROMIN I activities had been started, but its approval was contingent on disbursement of 50 percent of PROMIN I. Some PROMIN II funds were devoted to the same areas as those covered by PROMIN I, and some were used to expand the program to new locations. In most provinces, subprojects have been simultaneously financed by PROMIN I and PROMIN II. As discussed in Section E, the existence of PROMIN II may have affected the sense of urgency afforded the question of financial sustainability; it also gives the Bank and the Borrower an immediate opportunity to leam from experience. Three other significant changes were made in the project. First, in 1993, the Ministry of Education extended its formal education policy to cover children age 5 years; therefore, the Early Childhood Development component expanded its focus on younger children. Second, during execution the Borrower and the Bank agreed to reprogram funds that had originally been allocated for a set of national studies. Third, in 1996 the original training methodology of workshops, meetings and courses was changed to supervisi6n capacitante, in which local consultants, or facilitators, provided on-the-job instruction, within the work setting. 3.5 Quality at Entry: Satisfactory. In addressing an important problem (maternal and child wellbeing) and a key population (poor mothers and children), PROMIN scores high. In the technical work underpinning the design and the comprehensiveness of its interventions, PROMIN represented the best of the then-current thinking about optimal delivery of care to mothers and children through government facilities. -4 -  PROMIN I's design limitations lie primarily in two areas: First, the nutrition interventions were based on the belief that acute undernutrition was a serious problem in Argentina-a diagnosis that may not have been accurate at the time of design, and did not reflect conditions during implementation of the operation. Second, the child development component of the operation did not have a secure institutional home at the start, and few provisions were made to ensure that early childhood education, as conceptualized under PROMIN I, would be accepted by provincial Ministries of Education or other entities that could sustain it. One feature of PROMIN I's design that affected its performance is that it did not include interventions or policy changes intended to change the fundamental motivations and "rules of the game" underlying the behavior of public officials, individuals providing health and child development services, or members of poor households. In particular, no changes were introduced in the remuneration for services, labor markets, or in facility-level autonomy that could reinforce changes in provider behavior. To some observers, this represented a wise tactic, or at least a necessary one given the recent entry of the Bank into the health sector, the complexity of federal-provincial interactions in Argentina, and the considerable turnover at the political levels within the Ministry of Health. By requiring few difficult transformations-and thereby facing little or no opposition-PROMIN I was permitted to execute quickly, and served as a smooth introduction of the Bank into the Argentine health sector and an opportunity to improve services for poor mothers and children. Subsequently, a range of other operations have supported health insurance and public hospital reforns. Other observers believe that the lack of large-scale changes in the organization and financing of government health services jeopardizes the long-term continuation of the improvements in service delivery that were sought (and largely achieved) under PROMIN I. It is argued that health workers have no more motivation after PROMIN I than they did before the program to develop effective outreach programs, use information for decision making, or provide high quality care, although they may have the training, equipment and infrastructure to do so. Fundamental changes in provider behavior may require profound reforms of the sector. 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: Satisfactory. The PROMIN I operation performed well, yielding important and visible improvements in infrastructure and in the operation of health and child development services in some of the most disadvantaged urban areas of the country. Making funds available to provinces for infrastructure and other improvements in the delivery of services induced greater attention to MCH/N and child development, to the benefit of poor populations. Measurable improvements can be seen in the delivery of core maternal and infant health services, particularly in terms of respectful and regular care; at the same time, more opportunities became available for children in poor neighborhoods to be cared for in clean environments that provided at least a minimum level of nutritious food and psychosocial stimulation during the day. These are described in more detail in the sections that follow. -5 -  Despite these successes, questions can be raised about the extent to which the improvements will be maintained. As described in more detail in Section 6, in some jurisdictions there is limited potential for institutional and financial sustainability, particularly for the child development centers, which do not fit neatly into either health or education sectors. In addition, PROMIN I (as implemented, though not as designed) missed important opportunities for program improvement through monitoring and evaluation. 4.2 Outputs by components: A. Component 1: Maternal and Child Health and Nutrition. The main objectives for this component were in the realm of physical improvements and institutional development. Strictly speaking, the institutional development objectives of this component (as well as of the Early Childhood Development component) should be covered under the Institutional Strengthening component, which included all training, social communication and outreach funding. However, for ease of understanding, conclusions about these aspects of institutional strengthening are included in discussion of the substantive components. With respect to physical improvements, the operation is judged to be highly satisfactory. Some 195 health centers were rehabilitated, 75 health centers were built, and 8 maternity wards in hospitals were rehabilitated. Field visits during execution, as documented in supervision reports, indicate that the quality of the construction met or exceeded minimum standards. The average unit costs for civil works fell slightly below the Argentine average for Bank operations. With respect to institutional development-changes in health service management and health provider practice patterns-the operation is judged to be satisfactory. Approximately 1,922 health care providers were trained under the project, many using the supervisi6n capacitante methodology, which is widely viewed as effective. Supervision reports, the Borrower's Informe General de Cierre, and participants in the stakeholders' workshop indicated that visible improvements in MCH care provided at PROMIN-supported health centers included: introduction of an appointment system for patients, reduced waiting time for prenatal visits in many health centers; increased systematization of the content of pre- and postnatal care, and well-child care; development and maintenance of clinical histories for all patients; physical separation of sick and well patients at health centers; greater attention to standardized protocols for MCH care; and some progress on the difficult issues of greater delegation from physicians to nurses and improved referral and counter-referral between health centers and hospitals. In addition, there is evidence that the project had a positive effect outside of its target areas. In six jurisdictions (Jujuy, Moreno, Jose C. Paz, Parana and C6rdoba) training activities of PROMIN influenced non-PROMIN facilities and staff. While recognizing the achievements of PROMIN I in transforming the delivery of basic health services, it is important to acknowledge that the project fell short in areas that were essential to the comprehensive PROMIN modelo de atenci6n. First, the project did not foster the intended level of community outreach-i.e., health care workers actively seeking out pregnant women and infants to assess their needs and provide care. Second, the project did not succeed at stimulating the use of information for decision making about the delivery of services at the facility - 6 -  level. In addition to these shortcomings, the project did not implement the family planning counseling and related services foreseen in the design of PROMIN I. Positive process indicators have been seen in four mature subprojects (Rosario, Florencio Varela, Mendoza and Parana) that received only PROMIN I funds: in all, improvements can be seen in obstetric coverage, pediatric coverage and early prenatal attention (see Annex 1 for definitions). For example, in Mendoza, obstetric coverage increased from 15 to 58 percent between the start and the close of PROMIN I. Pediatric coverage increased from 23 to 55 percent. And early prenatal attention (captaci6n temprana) increased from 24 to 68 percent. Similar gains are seen in the other subprojects (ref Informe General de Cierre, page 227). Definitive statements about the health impact of PROMIN I cannot be made due to: (a) the lack of baseline data on the population affected by the program; (b) the difficulty of identifying appropriate control groups; (c) the weak information base with which to retrospectively construct "before PROMIN" health status indicators; and (d) the overlap of PROMIN I and PROMIN II in all but four subprojects. Despite methodologic challenges, with the Bank's encouragement (and using PROMIN II funds) an evaluation of PROMIN I's results was conducted in early 2000 using reconstructed before-PROMIN indicators as well as some PROMIN-non-PROMIN comparisons. That study concluded that in the area of infant mortality, the project interventions did not affect the proportion of infant deaths due to preventable causes. With respect to childhood illnesses, PROMIN I did not affect the prevalence of diarrheal disease or acute respiratory infection. Similarly, the evaluation found that PROMIN I did not affect the (already low) prevalence of low birthweight. Finally, PROMIN I did not affect the nutritional status of children (ref Informe General de Cierre, Annex I, 2000). The most likely explanation for these findings is that the health status indicators that PROMIN I was designed to affect, such as infant mortality, are sensitive to many influences outside of the health sector, including household behaviors and environmental conditions. The country as a whole achieved significant improvements in maternal and child health during the relevant period, and it is likely that PROMIN I contributed in some manner to the general trend. Between 1990 and 1997, for example, infant mortality declined from 25.6 per 1,000 live births to 18.8 per 1,000, and the proportion of infant deaths attributable to preventable causes fell. Neonatal mortality declined from 15.6 per 1,000 in 1990 to 11.4 per 1,000 in 1997; post-neonatal mortality fell from 9.4 to 7.0 per 1,000 during the same period. Maternal mortality decreased from 52 per 100,000 in to 38 per 100,000 in 1997. Indicators of health service coverage, such as immunization rates, showed steady improvement (ref Metas en Favor de la Madre y el Nino para el Ano 2000, Ministry of Health, 1999). B. Component 2: Early Childhood Development. PROMIN I sought to make both physical and organizational improvements in the area of early childhood development, where basic infrastructure was much weaker than in the health sector. Again, in terms of physical improvements, PROMIN I performed in a highly satisfactory manner, providing funding and technical oversight for the construction of 153 Child Development Centers, many in precarious locales. -7 -  In terms of institutional development in child development, PROMIN I was marginally satisfactory. Approximately 1,739 child development workers (including Promotoras) received training under the project, and the training is reported to be of reasonably high quality. However, institutional development in the area of child development was weak in two ways: First, the child development centers and workers did not have a clear institutional home. Few links were established with the national or provincial Ministries of Education, and there is evidence that Ministries of Education expressed unwillingness to accept or adopt the model of semi-formal early childhood education promoted under PROMIN I. Trained child development workers and Promotoras were not seen by Ministries of Education as having legitimate teaching credentials. At the same time, early childhood development was not seen as a mainstream activity within the health sector. Second, the original ambition of the PROMIN model was to have close coordination between child development and child health: children in the CDIs were all to obtain optimal well- and sick-child care at PROMIN-assisted health centers. In fact, coordination varied greatly from one jurisdiction to another, and is reported to be inadequate in most. Among the four subprojects studied in depth for the evaluation of results, there were almost no instances of regular meetings or other contacts between the PROMIN health and child development centers. Given current data, the impact of PROMIN I interventions on child development is impossible to measure. Overall, coverage of the preschool population varied greatly across subprojects. Underutilization of the centers, attributed to low effective demand on the part of parents, has been a problem in half of the CDIs. On the other hand, there are success stories; in Gran Mendoza, where child development fit squarely into the province's social policy, the CDIs cover 75 percent of the target population, and demand is high. With respect to cognitive and psychosocial outcomes, about 80 percent of the children participating in CDIs have overall development levels that are ranked as "good" or "very good," and 60 percent are reported to have adequate intellectual and language development (Informe General de Cierre, p 175). However, without comparisons to children not participating in the CDI, no conclusions can be drawn about effectiveness. (A study comparing CDI vs. non-CDI children on school performance is currently underway, and results are expected in late 2000.) C. Component 3: Institutional Strengthening. As noted earlier, although institutional strengthening was described as a separate component in the SAR, in fact the majority of the activities under that component were integral to the components discussed above, and are therefore assessed under those components. A small but important share of the activities under institutional strengthening sought to enhance program implementation capacity at municipal, provincial and national levels. We cover only this latter set of activities in this section. PROMIN I is rated marginally satisfactory in the area of institutional strengthening. On the positive side, the requirements for subproject design contributed to improvement in information-based planning and monitoring of health and child development investments. Extensive efforts were made by both the Borrower and the Bank to develop and improve upon the system for monitoring project performance and health information systems related to maternal - 8 -  and child services. Tools such as supply and demand analyses, including beneficiary surveys, were introduced to the jurisdiction authorities by the project. Some of the training strengthened planning and coordination functions within provincial and municipal health authorities. And there were some "pasantias de cooperaci6n horizontal," in which staff from the Provincial Executing Units, the Municipal Executing Units and the Ministry of Health in a given province exchanged experiences with corresponding staff in other provinces. Bank staff familiar with the execution of the operation note that despite the fact that the project was implemented through dedicated Provincial and Municipal Execution Units, "nearly always, the Bank team found the MOH officials highly committed to the PROMIN project, very aware of the details of what was going on, and usually wanting to do more" (ref communication with Jean-Jacques de St. Antoine, 6 September 2000). On the other hand, the Government's Informe General de Cierre and comments by some jurisdiction authorities at the stakeholders' workshop indicate that the Provincial and Municipal Executing Units, which operated under the direct supervision of the central Project Coordinating Unit (PCU), tended to work in parallel to Ministries and Secretaries of Health at the corresponding levels, and the project did not strengthen the management capacity in the line agency substantially. At the federal level, the Project Coordinating Unit reported directly to the Minister of Health, rather than to the technical counterparts in the Department of Maternal and Child Health-a structure that had the dual effects of efficient implementation and weak coordination within the Ministry. In addition, it is widely acknowledged that infornation systems under the operation fell short of expectations, despite the fact that monitoring and evaluation was a hallmark of the original design. The process of adapting the list of 47 performance indicators inventoried in the SAR (ref Annex F) to a list of 24 indicators that were used to monitor progress (ref October 1-26, 1994 supervision mission aide-memoire) was time consuming, and when complete did not result in a monitoring system that was used by implementers at all levels for decisionmaking. As documented in virtually all the supervision mission reports and the Informe General de Cierre, the information system was fragmented, less useful for planning and program management than hoped, and did not induce the type of significant cultural shift necessary to use informnation in a systematic manner for day to day management decisions. The several studies to be funded by PROMIN I under the Institutional Strengthening component, including the Impact Evaluation, the National Health and Nutrition Survey, Evaluation of Supplementary Feeding Programs, and the Study of the Reformulation of Comedores Escolares, were canceled, greatly reduced in scope, or shifted to PROMIN II. For a variety of technical and financing reasons, the Impact Evaluation was delayed and eventually shifted to PROMIN II; baseline data for PROMIN I were not collected. The National Health and Nutrition Survey was canceled, first, because the original bids far exceeded the budget, and second, because national counterpart funds were in short supply and priority was afforded to subprojects. The study of the Refornulation of Comedores Escolares was carried out in the form of smaller studies in 9 provinces; some of the resulting recommendations were implemented. The Evaluation of Supplementary Feeding Programs was not conducted, although smaller studies -9-  related to this topic were financed under subprojects. 4.3 Net Present Value/Economic rate of return: Not Applicable 4.4 Financial rate of return: Not Applicable 4.5 Institutional development impact: Modest. As described in detail in Section 4.2, PROMIN succeeded in improving some aspects of the organization and functioning of basic health care services, and improved planning of MCH/N services in the provinces and municipalities under the program. Because of PROMIN's small size relative to the sector, and the absence of policy- and structure-related interventions, it did not create large-scale changes in institutional efficiency or capacity. 5. Major Factors Affecting Implementation and Outcome 5.1 Factors outside the control of government or implementing agency: Not Applicable 5.2 Factors generally subject to government control: Three factors subject to government control were found to be detrimental to PROMIN I's implementation and outcome. First, during the financial crisis affecting Argentina in 1997 and 1998, counterpart resources were scarce and several activities were negatively affected. Second, less emphasis was put on monitoring and evaluation, including national studies, than was originally anticipated. Finally, as noted earlier, although the original health care package for women included reproductive health in general, and provision of family planning in particular, family planning services were never implemented or supported under the project. While this may have reflected the prevailing values of the government, from a health perspective-in the context of relatively high maternal mortality and high prevalence of unsafe abortions-it reduced the potential positive impact. 5.3 Factors generally subject to implementing agency control: The number of people employed to manage and administer the PROMIN I operation was larger than anticipated originally. Although precise figures are difficult to obtain because many long-term consultants were hired under arrangements managed by the United Nations Development Program and the International Organization of Migration, the staff at the central PCU grew from about 50 in 1993 to 80 in 1999. By 1999, another 104 people were employed in the provincial executing units (ref Informe General de Cierre, page 169). The share of project funding used for the Project Coordination Unit, estimated at 9.5 percent in the SAR, ended up at -10-  15.4 percent. 5.4 Costs andfinancing. Two aspects of costs and financing are noteworthy: Reallocation of project resources toward civil works, and difficulties in mobilizing counterpart funds both during project execution (as noted earlier) and as the provinces and municipalities were required to take responsibility for a larger share of recurrent costs. As shown in Annex 2, expenditures on national studies and on human resources (service providers) within subprojects were lower than originally anticipated, and spending on infrastructure and coordination were correspondingly higher. The proportion of the project funds that were expected to be allocated to national studies was 7.4 percent (or US$12 million); this ended up at zero. The share of project monies expected to be devoted to infrastructure was 27.6 percent. By the end of the project, this had risen to 42.5 percent. As in many other projects, it is likely that civil works were emphasized because of the prevailing opinion by the general public and political leaders that visible improvements in infrastructure is equivalent to upgrading service quality. Many of the subprojects experienced problems with mobilization of counterpart funds, particularly for the child development activities. For example, in Tucuman, the province's inability (or unwillingness) to pay wages or monetary incentives for workers in PROMIN-supported facilities led to an early termination of the subproject. In Florencio Varela, while health workers' salaries were covered by the public sector, monetary incentives for Promotoras in the CDIs ceased at the close of the project. In Parana, again the health workers were covered under the public sector payroll, but due to concerns about the labor market status of the Promotoras, the jurisdiction never paid monetary incentives and the CDIs suffered from high rates of worker absenteeism as a result (ref Estudio de Costos, pagel 3-14). 6. Sustainability 6.1 Rationale for sustainability rating: It is unlikely that the majority of the benefits of the PROMIN I operation other than those related to infrastructure development will be sustained unless new Federal funding mechanisms are developed, or priorities change at the provincial level. Even the physical improvements may not be maintained over time due to insufficient allocation of financial resources and commitment by the owners (provinces and municipalities in the case of health centers and hospital wards, community groups and municipalities in the case of the child development centers). This judgment is made on the basis of the experiences in the four subprojects that have closed; the other subprojects continue to receive PROMIN II funding and therefore do not immediately face the problem of financing recurrent costs out of provincial budgets. Careful attention to the issue of sustainability under PROMIN II could result in a better outcome than now predicted. The reasons for this rating include: - 1 1 -  a) In Argentina, where the responsibility for financing and operating public health services is held by the provinces, the federal government has, to date, played a relatively small role in the sector. Federally-managed programs such as PROMIN can be used as tools to encourage improvements and reorientation of priorities at the provincial level. But this is likely to be a successful strategy only where the programs are truly integral to and consistent with the provinces' own broader plans for health sector development. An isolated program, especially when the implementation is controlled (directly or indirectly) through a central unit, is unlikely to have a life after the subsidies cease. In the case of PROMIN I, the level of commitment and political will, particularly with respect to sustaining Early Childhood Development activities, appears to be quite low in many of the participating provinces and municipalities. This situation, combined with increasing pressure on public budgets, makes it unlikely that the resource-intensive PROMIN model will be sustained. On the other hand, it is worth noting that for health investments in several municipalities, there has been a high level of commnitment. In Rosario, for example, official report that health centers that received PROMIN I funding will continue to be supported, and that the model will be expanded throughout the jurisdiction. b) The stringent budget conditions now prevailing in Argentina place all investments at risk, and minimize the chances of government support for the additional personnel, training, social communication and other recurrent costs associated with the PROMIN model. The project design anticipated a gradual transition in the financial responsibility for recurrent costs, but very few of the costs have been taken up completely in the participating provinces or municipalities. As described above, this is particularly problematic in the Early Childhood Development component of the project. Virtually none of the jurisdictions are able (or willing) to finance the required new personnel, or continue to provide monetary incentives to the Promotoras. c) The child development centers are poorly integrated into either education or health sectors, and operate outside of a fixed institutional framework. While this may give them some advantages in terms of flexibility, the fate of child development workers and building maintenance is precarious in the absence of an institutional home. d) The use of non-governmental organizations in implementation has been limited, and the commercial private sector played no role in the project. Social audits were conducted by the Red Cross and Caritas in some subprojects, and Caritas operated a number of CDIs. In addition, NGOs were used to some extent as part of social communication campaigns. However, the project did not involve NGOs as a means of building a broad-based constituency for the project, or to mobilize diverse funding sources. It did not seek to stimulate development of better MCH/N activities in the private sector. e) The government's Informe General de Cierre and participants in the stakeholders' workshop indicated that in many, though not all, of the jurisdictions, the execution of the project through administrative structures that ran parallel to the existing public sector entities weakened the prospects for long-term sustainability. t) The absence of an impact evaluation based on reliable pre-PROMIN information-even for - 12 -  small sample of "demonstration" areas-means that it is not possible to analyze the cost-effectiveness of the PROMIN model. This knowledge gap severely limits the ability of proponents of the approach from justifying continued outlays on the basis of a sound economic analysis. Aside from uncertainty about financial sustainability, which applied primarily to the Early Childhood Development component, questions remain about the likelihood that the changes in provider practices will be sustained without corresponding sector-wide modifications in the organization and financing of health services. As has been experienced in other countries, better infrastructure and equipment and more training may be insufficient to improve the productivity and consumer-responsiveness of government health workers. 6.2 Transition arrangement to regular operations: The extent to which the project activities will be shifted to regular operations is unclear, in part because of the availability of PROMIN II funding. Ability to eventually take over financial and institutional responsibility for PROMIN activities was an eligibility criterion for subprojects, and each of the agreements between the central Ministry of Health and the jurisdictions included clauses related to the gradual shift in financing to the jurisdictions' budgets. However, there is little or no enforcement of this commitment, and in the large majority of project areas funding continues under PROMIN II. Despite an agreement between the Borrower and the Bank in 1999 that sustainability plans would be prepared for each of the subprojects that were closing, no formal sustainability plan exists, and currently there are no plans to develop one. In two of the five jurisdictions that received only PROMIN I support (and where the subprojects have already closed), the transition to public budget financing remains possible but unlikely; in two others, due to strong political will, there is a good chance that the public sector will take on the added responsibilities for the health sector activities but not for child development. In the final jurisdiction (Tucuman), the subproject closed prematurely due to the jurisdiction's failure to provide counterpart for either health or early childhood development activities. 7. Bank and Borrower Performance Bank 7.] ILending: The Bank performed in a satisfactory manner during project preparation, identifying an important set of interventions during an opportune moment for the Borrower. The Bank depended primarily on technical work developed by a UNICEF team, which was of high quality and met existing Bank standards. Two shortcomings during the appraisal period were: (1) The minimal involvement of government counterparts. Justified on the grounds that technical capacity in that unit was weak at the time, this tactic was largely responsible for decisions that led to establishing executing structures that were not fully integrated into the public sector management line authorities. (2) Inadequate attention to ensuring that the recurrent cost burden could and would be absorbed by - 13 -  the jurisdictions at the close of the project. 7.2 Supervision: Supervision of the project was satisfactory. Compared to many Bank operations, there was remarkable continuity on both Bank and Borrower sides: For the four years of most intensive activity, 1994-98, the composition of the executing team on the Borrower side was almost unchanged; on the Bank side, the task manager and field-based procurement specialist remained the same, as did the two consultants who were assigned to supervise the construction quality and the implementation of the modelo de atenci6n. In stark contrast to many Bank operations, ratings in the supervision reports started relatively low and improved markedly during the life of the project. Initially, as considerable effort was expended setting up information and other systems, disbursements and other progress indicators lagged; supervision reports from that period express frustration with the slow pace. By mid-1994, the executing team had changed to one that put a greater emphasis on execution. At the same time, a fresh Bank team solved some of the execution obstacles. For example, the Bank procurement specialist worked with the government team to improve the bidding documents for "local shopping" (the primary procurement methodology for civil works), thereby expediting procurement and lowering construction costs. The project cycle for preparation, evaluation and approval of subprojects was also streamlined. Between 1995 and 1997, as the pace of commitments and disbursements quickened, supervision reports and accompanying aide-memoires and the mid-term review expressed satisfaction with progress, and included a series of recommendations that addressed specific issues in the organization and delivery of MCH/N services; in addition, under the Early Childhood Development component, the supervision team provided recommendations about child feeding issues and coordination with health centers. In the area of information systems, stronger recommendations were made regarding the pace and technical adequacy of monitoring mechanisms. Outside consultants were brought in to assist with development of indicators and creation of a functional information system. By 1998, when a new task manager (with the same consultants) supervised the operation, PROMIN I attained the rating of "highly satisfactory" for both development objectives and implementation. Although certainly meeting or exceeding minimum standards, supervision of the PROMIN I operation could have been improved in several ways: First, more critical attention could have been given to the uneven progress in transformation of the modelo de atenci6n within health centers. Second, a greater and more effective effort could have been made to address the lack of a feasible and enforceable plan for transferring financial responsibility at the close of the project. In the end, agreement to prepare such a plan did not result in its creation, or in the important outcome of an actual shift in financial responsibility. Third, stronger supervision of the Early Childhood Development component was - 14 -  warranted. While receiving about half of the project funding, this component received markedly less technical oversight than the MCH/N component. The original supervision plan included 8 weeks of time from a child development specialist, but no one with special qualifications in the area of early childhood education participated in supervision missions. Throughout the course of the project, the main technical emphasis was on MCH/N (as indicated by the number of recommendations and agreements presented in aide-memoires, the monitoring indicators, and the frequent description of the project as a "maternal and child health project" in Bank documentation). Finally, the Bank acceded to a series of modifications (and elimination) of the national studies included in the original design. In hindsight, lack of baseline data for an impact evaluation has severely limited the ability of both the Bank and the Borrower to assess the wisdom of investment choices. 7.3 Overall Bank performance: Satisfactory Borrower 7.4 Preparation: To prepare the overall framework for the operation, the Borrower depended largely on the work of the UNICEF technical team-several of whose members went on to constitute the original executing team of the project. The later preparatory work during design of subprojects was done largely by provincial and municipal health authorities. 7.5 Government implementation performance: In general, the government permitted unconstrained implementation of the PROMIN operation, and in that way was supportive. 7.6 Implementing Agency: For much of the project's life, the implementing agency (i.e., the PCU within the Ministry of Health) understood its mission to be execution of the main aspects of the project, with particular emphasis on infrastructure and training. It performed that role well. The system for issuing bidding documents, evaluating bids, overseeing contracts, and maintaining accounts was very effective, although it came at a higher administrative cost than originally anticipated. In the view of the Bank's procurement specialist, the PROMIN I operation in general met high standards for transparency, and prevented excessive cost overruns. As stated earlier, monitoring of the technical aspects of the program was not as strong. In addition, technical specialists rarely worked with individuals in the PCU charged with monitoring disbursements; thus, spending patterns were disconnected from technical priorities. 7. 7 Overall Borrower performance: Satisfactory - 15 -  8. Lessons Learned Financial sustainability is the lynchpin. In hindsight, it is clear that the provisions for financial sustainability of PROMIN I investments were weak, and that the substantial benefits of the operation are jeopardized by an inadequate and unrealistic assessment of the province- and municipal-level willingness to take responsibility for continuing and expanding the PROMIN interventions. In this context, it is important to note that financial sustainability implies much more than mechanistically finding budget space for additional recurrent costs. Budget allocations reflect political priorities. Thus, emphasis on financial sustainability of PROMIN would have demanded that attention be paid, at the outset, to developing intellectual ownership of the program by the leaders in the health sector, and strengthening that through evaluations that could provide hard evidence of the project's achievements. Emphasis on financial sustainability would have informed decisions about the institutional arrangements for execution: If the provincial ministries were eventually to take over operation and expansion of the program, their involvement in day to day execution was essential. Such an emphasis would have forced a resolution to the issue of the institutional isolation of the child development activities long before the end of the project. Tackling the question of financial sustainability, and the associated elements of Borrower "ownership," is a major challenge for Bank operations, and makes project appraisal and supervision more difficult and time-consuming. The incentives to do so are few, particularly when continued Bank support is available (as in this case, under PROMIN II). The lesson for future operations in Argentina is that Bank management should pay close attention to the strength of the assumptions underlying statements about prospects for sustainability. Visible investments are important. but not enough. Although Argentina is among the region's richest nations, the health sector-and particularly the public health sector that seeks to serve the low-income families without explicit health insurance-remains in a poor state of physical and technical development. This is reflected in health indicators that are inferior to other countries at lower income levels. The infusion of external resources targeted at tangible improvements in basic health services has been universally viewed as a positive outcome of PROMIN I. However, investments in civil works, equipment and training have not been sufficient to induce the profound changes in the culture of health care provision originally envisioned. The "rules of the game" remain the same; thus, provider and consumer behavior are largely unchanged. It is impossible to know whether, with a different design, PROMIN I could have promoted sectoral reforms that would have altered the behavior of providers and patients over the long term. Political and institutional obstacles to change might have simply resulted in the project's paralysis and ultimate failure. However, it is likely that PROMIN I could have made a greater long-term contribution if it had been viewed by its designers and implementers as an initial step - 16-  toward a health system in which the organization and financing were aligned toward achieving results and responding to demand. It could have been part of a reform-oriented vision, rather than isolated from it. Specifically, that perspective would have made evident the need for good monitoring systems that could respond to local-level information needs. It could have induced provinces to use project resources to pilot test new provider payment systems. In the future, and over the long term, important improvements in the provision of health services and early childhood education for the poor will require attention to questions of policy, structure, financing and stimulating demand, rather than to construction and training for specific programs. "Demand-driven" projects can surprise us. Originally, project designers assumed demand for rehabilitating, equipping and staffing health centers would far outrun demand for child development investments. As it turned out, many provinces and municipalities in fact requested large sums for construction of CDIs and training of staff. This shift was somewhat difficult to detect, however, because the technical specialists in the PCU (as well as Bank staff and consultants) did not track the disaggregated disbursement patterns that were under the purview of PCU's financial team. As a result, the emphasis of supervision continued to be on the health and nutrition components. Monitoring and evaluation need special attention. In PROMIN 1, as in other Bank operations, good intentions about careful monitoring and evaluation gave way to the pressures to produce visible improvements-and to use the financing in a timely manner. This reduced PROMIN's usefulness as a demonstration project for better delivery of core maternal and child health services, or as a pilot effort to develop and improve upon early childhood development interventions. In Argentina, which has a weak tradition of evaluation, the priority given to monitoring and evaluation in the project's design could only have been maintained if both the Bank and the Borrower considered that the "knowledge" output of the project was as important as the physical outputs, and/or if the project had been structured so that financing of subprojects, which was in high demand, was contingent on producing baseline and monitoring data. Parallel executing structures can impede institutional sustainabilitv. Depending on the specifics of a given setting, it may be wise for the Bank and Borrower to design arrangements for project implementation that do not include the development of large, semi-autonomous executing units. This issue is currently being addressed within PROMIN II, where the coordination unit is being incorporated into the Ministry's Direcci6n de Salud Materno-Infantil; similar changes are being encouraged at the provincial and municipal levels. A successful demonstration area would have been an invaluable asset. An early investment in creating a pilot demonstration center to highlight the full range of PROMIN interventions would have greatly assisted in maintaining the understanding of the importance and economic returns of the integrated modelo de atenci6n. The impact of PROMIN II can be greater than the impact of PROMIN I. Although all of the PROMIN II resources have been committed, several specific lessons from the assessment of PROMIN I can be used to enhance the impact of the follow-on operation. These include: Develop baseline indicators for new subprojects. - 17 -  Obtain a clear expression of political will to assume recurrent cost responsibilities, and build in enforcement mechanisms. - Improve on the information system to make it more usable (and used) by direct service providers. * Re-enforce outreach activities to overcome demand-side barriers. Strengthen the referral/counterreferral system, which remains weak. * Ensure that the nutrition interventions are directed more to the problem of chronic undernutrition than acute undernutrition. * Seek synergies with other national primary care programs (e.g., midicos de cabacera). * Document highly successful instances in which the modelo de atencion was fundamentally transformed. * Reorient the activities under the Early Childhood Development component if warranted after a more thorough assessment of the prospects for institutional and financial sustainability in each of the subprojects. 9. Partner Comments (a) Borrower/implementing agency: These are the comnments received from the Project Coordination Unit in the Ministry of Health in Argentina on September 15, 2000. Acerca de la calificaci6n del Promin I en general 1. Una observaci6n general que hace al metodo de presentaci6n: llama la atenci6n la discordancia que se nota entre algunas calificaciones que se colocan en los subtitulos (por ejemplo pto. D en que se califica de satisfactorios los resultados del Promin) y el texto que da contenido a dicha calificaci6n (que es severamente critico). Por nuestra parte, el examen de cada uno de los componentes sustantivos del proyecto y de las areas de apoyo (administrativas), que se realiza en estas notas y comentarios nos permite concluir que el conjunto de la gesti6n e implementaci6n merece el calificativo de medianamente satisfactorio. El peso relativo de la poblaci6n objetivo 2. Debe revisarse la estimaci6n del significado porcentual de las madres y nifios pobres atendidos por el programa respecto al conjunto de la poblaci6n carenciada. En el ICR se afirma que esta proporci6n, es del 5%, esta es una afirmaci6n, a nuestro juicio err6nea que debiera corregirse. Segiin el Censo Nacional de Poblaci6n de 1991 (uiltimo dato oficial, y por otro lado base de los calculos del Promin) la "poblaci6n en hogares con NBI" ascendia a 6.427.257 (es decir el 19,9% de un total de 32.245.467 personas). Analizando la piramide por sexo y edad correspondiente a dicho censo, se observa que las mujeres en edad fertil (15-49 anios) y los nifios menores de 6 anios constituyen - aproximadamente- el 40% de la poblaci6n total; proporci6n que se eleva al 43% en el caso de la poblaci6n en hogares con NBI. 3. Por lo tanto, en cifras absolutas en hogares con NBI en todo el pais, la cantidad de - 18 -  mujeres en edad fertil y de ninos menores de 6 afios ascendia por entonces a unas 2.763.721 personas. De este modo, las aproximadamente "500.000 mujeres y nifios de areas urbanas con bajos ingresos" que el programa buscaba beneficiar, representan en realidad el 18,09% del total de mujeres en edad fertil y nifios menores de 6 afios que habitan en hogares con NBI. El modelo de atenci6n y la estructura de inversiones 4. En el punto C. Objetivo General se comenta acerca del modelo Promin: ..."siguio una vieja estructura de inversiones...". Esto resulta parcialmente cierto ya que al momento de la formulaci6n e implementaci6n del proyecto, esta era practicamente la unica hip6tesis propuesta a nivel de las politicas puiblicas nacionales destinada a la transformacion de la deficiente estructura de servicios destinada a la atenci6n de madres y nifios residentes en areas carenciadas de los centros urbanos del pais. Conviene recordar que en ese momento, funcionaban (y ain continuian actuando) como forma muy primitiva de complementar las necesidades alimentarias de los nifios en edad pre - escolar, los denominados comedores infantiles o comunitarios, surgidos como respuesta espontanea de la poblaci6n ante la crisis hiperinflacionaria del 89' y apoyados luego con fondos piiblicos. Frente a esta forma tosca y no planificada de enfrentar las necesidades de este grupo socialmente tan vulnerable la propuesta de los CDI, resultaba no s6lo novedosa, sino un verdadero desafio para superar el asistencialismo provisorio remplazandolo por una perspectiva de promoci6n destinada a equilibrar las desventajas de los nifios con NBI al momento de integrarse al sistema educativo formal. En el area de salud, paralelamente, la propuesta de fortalecer el sistema de atenci6n primaria y su sistema de referencia, revitalizando el equipamiento y la obra civil y primordialmente el metodo de atenci6n de la poblaci6n matemo infantil cubierta por el mismo (en las areas carenciadas) se fijaba como objetivo proporcionar a estos segmentos sociales el acceso a servicios que hasta el momento s6lo nominalmente estaban disponibles para este fin; ambas situaciones siguen vigentes aun hoy. La importancia de la pobreza en los centros urbanos elegidos 5. En el punto C de referencia se afirma, en el parrafo sobre los componentes originales del mismo, que las provincias de Buenos Aires, Sante Fe, C6rdoba, Entre Rios, Mendoza, Tucumrn si bien se caracterizan por sus grandes centros urbanos no lo son por los altos niveles de pobreza. Vale la pena recordar al respecto, que para 1991 la poblaci6n urbana del pafs constituia el 87% de la poblaci6n total y que mas del 80% de la misma se concentraba en los grandes centros de estas 6 jurisdicciones, proceso que en diez anios se ha acentuado. Cabe agregar que siendo la pobreza actual en Argentina una manifestaci6n sobre todo urbana, esos centros concentran una proporci6n enorme de la poblaci6n carenciada de todo el pais medida por las necesidades basicas insatisfechas o por los bajos ingresos, segun el citado censo estas seis provincias concentraban en sus centros urbanos el 59.2% del total de poblaci6n con necesidades basicas insatisfechas de - 19 -  la Argentina. Por otro lado - como es esperable en funci6n de las magnitudes antes mencionadas - los niveles de pobreza (siempre medidos por el indice de NBI) de estas provincias (el 17.7% del total de la poblaci6n), no estan muy por debajo del promedio urbano de todo el pais (19.9 %). Sin embargo es cierto que algunas jurisdicciones como Santiago del Estero, San Juan, Chaco, Corrientes, etc., tienen una escasa proporci6n de la poblaci6n total - urbana y rural - y altas proporciones de poblaci6n NBI (alrededor del 30%). Las falencias de los sistemas de seguimiento y evaluaci6n en desmedro del cambio del modelo de atenci6n 6. En el parrafo sobre componentes examinados se afirma que los componentes del programa no "fueron formalmente examinados durante la ejecuci6n de la operacion.. .No obstante, [se dice] se introdujeron cambios en el alcance geografico, en la escala de los subproyectos, y en el contenido de las intervenciones...". Efectivamente como el propio texto lo sefiala mas adelante los diversos estudios evaluativos que hubieran permitido controlar tanto el cumplimiento de metas, como la direccionalidad del proceso de transformaci6n propuesto y que eran parte del proyecto original, fueron abandonados y los fondos destinados a los mismos reprogramados y asignados a obras de infraestructura y equipamiento. Unido esto a un deficit notorio del sistema de monitoreo, condujo a problemas que dificultaron notoriamente la toma de decisiones y el gerenciamiento criterioso de los proyectos en ejecuci6n, como en la selecci6n de nuevas areas y subproyectos. Este abandono de los criterios de control gerencial, sumado a una ausencia de una abogacia por parte de la UCP en la modificaci6n del modelo de atenci6n, incluso utilizando los mecanismos previstos por el proyecto, afectaron directa e indirectamente en la perdida de objetivos especificos en lo que se refiere a los cambios propuestos en el modelo de atenci6n: resulta inaccesible para cualquier equipo central de conducci6n de un programa controlar aspectos complejos como son los de la atenci6n programada de la salud, el cumplimiento efectivo de los mecanismos de relaci6n entre los centros de atenci6n primaria y sus centros de derivaci6n (referencia y contrarreferencia), los cambios de orden operativo en la atenci6n de la demanda, etc, sin la existencia de elementos informativos basicos para sustentarlos. La calificaci6n de los componentes del Promin I 7. Un juicio contradictorio en el punto C, es el que se refiere a la calificaci6n del contenido del Promin, tema que analizamos en el primer parrafo de estas notas, ya que por un lado se dice que es satisfactoria al inicio, a pesar de que se visualizan en el mismo ciertas debilidades, que se sintetizan en el ICR en cuatro areas: falta de incentivos para los funcionarios publicos en servicios de salud y desarrollo infantil; el enfasis en la mejora de la oferta sin considerar los obstaculos de la demanda; el diagn6stico sobre desnutrici6n aguda "como problema serio en Argentina"; finalmente el propio componente de desarrollo infantil [se dice], no cont6 con un "lugar seguro al inicio... no lograndose que la educaci6n temprana, tal como fuera conceptualizada por el Promin fuera aceptada por el Ministerio de Educaci6n..." - 20 -  Inviabilidad de incentivos particulares para los recursos humanos de los efectores del Promin I 8. Respecto a estos puntos el Ministerio de Salud, a traves de la Unidad Coordinadora de Programas Matemo Infantiles y Nutricionales sostiene que los incentivos particulares basados en la productividad para los funcionarios implicados en la instrumentaci6n de los subproyectos fueron motivo de extenso analisis en la formulaci6n inicial del Promin y se desecharon entonces, ya que dichos incentivos resultarian contradictorios con las politicas salariales de las jurisdicciones en donde se intervendria ( en las que priman las retribuciones homogeneas segun cargo y funci6n) y por tanto no resultarian sostenibles en el tiempo, una vez terminado el pago de recursos humanos con fondos del programa, situaci6n que aun hoy se mantiene vigente en la politica de recursos humanos del sector publico, y que en la totalidad de las provincias esta juridicamente consagrada tornando inviable esta propuesta. Por otro lado el tema de los incentivos implicaban, a juicio del grupo de formulaci6n, una diferenciaci6n obstructiva entre los agentes que trabajarian en un mismo ambito segun fuera su fuente de fmanciamiento (Promin y no Promin). La transformaci6n de la oferta y de la estructura de la demanda 9. Respecto a las consideraciones sobre el mejoramiento de la oferta, creemos que si bien en la programaci6n se enfatizaron los cambios en esta (como base del nuevo modelo de atenci6n), en la propuesta original la transformaci6n de los obstaculos originados por la estructura de la demanda estaban previstos y se consideraron pasibles de cambio a traves de un proceso de comunicaci6n social intenso y de educaci6n para la salud asi como de la aplicaci6n de una captaci6n activa de la demanda no satisfecha con trabajo extra-mural del equipo de salud y aplicando una metodologia de programaci6n local. Por cierto este es una propuesta que contrasta con la visi6n "politica" (muy propia de muchos politicos provinciales y municipales) que reducen la transformaci6n de la oferta a la construcci6n de nuevos efectores o a su equipamiento (como forma de demostrar su preocupaci6n por el sector y los logros obtenidos) y que curiosamente coincide con una creencia del puiblico beneficiario (al menos temporaria) de que la inversi6n fisica es la puerta de entrada a una mejor atenci6n, rapidamente descubren, sin embargo, que sin un recurso humano adecuadamente entrenado y motivado e insumos adecuados, el cambio en la estructura fisica de los recursos resulta un espejismo para alcanzar logros que se reflejen en indicadores de procesos y resultados. El enfoque nutricional: el problema del diagn6stico 10. En cuanto al tema de la desnutrici6n, efectivamente las consideraciones originales en que se bas6 el diagn6stico de desnutrici6n aguda, compartida por el grupo de preparaci6n del proyecto y los tecnicos del BIRF, utiliz6 la informaci6n - por cierto insuficiente - que entonces se disponia a este efecto. La conciencia plena de la limitaci6n de la informaci6n disponible entonces, llev6 a que uno de los estudios aprobados y que despert6 mayores expectativas, en el conjunto de los propuestos por el Promin, fue - 21 -  justamente el de la Encuesta Nacional de Nutrici6n, desechada en el transcurso de la gesti6n de implementacion posterior. El enfoque epidemiol6gico original se basaba en un paradigma de defidict cal6rico-proteico. Desde el punto de vista de politicas publicas el problema que se presentaba en relaci6n con la complementaci6n alimentaria era como enfrentar la diluci6n intrafamiliar, de allf las caracteristicas con las que se diseino la caja (CAF). El estudio de resultados de la implementaci6n del CAF en 1999, demostr6 sus falencias, lo que, unido a estudios recientes sobre deficits nutricionales en la poblaci6n matemo-infantil (fundamentalemente micronutrientes) llev6 a redefinir la politica de complementaci6n alimentaria transformando la propuesta de complementaci6n alimentaria en la de entrega de leche fortificada con sales de hierro y zinc a partir del ano 2000. El desarrollo infantil: una de las caracteristicas fundamentales del PROMIN 1. El otro punto a comentar es el de las observaciones al enfoque del area de desarrollo infantil, uno de los aportes, a nuestra consideraci6n, genuinamente mas novedosos del Promin, en tanto que a partir de la formulaci6n del proyecto, la idea de la integralidad de la problematica de los pre - escolares se convirti6 en tema obligado de la agenda de las politicas publicas sociales de la Argentina. Conviene recordar la tajante e inequitativa divisi6n que se presentaba en este tema, al inicio del programa (y que en lo esencial se mantiene aun hoy) entre la abundante oferta de jardines de infantes destinados a los ninios en edad pre - escolar de los segmentos sociales medios y altos y la precaria oferta que para los nifios de los sectores carenciados estaba constituida por los comedores comunitarios o infantiles, reducida a una elemental y reducida prestaci6n alimentaria . Desde el inicio de la preparaci6n del proyecto, se asumi6 que frente a esta grave situaci6n, el CDI como transformaci6n de estos comedores, debia constituirse en el nuicleo efector de una novedosa y superadora modalidad de estimulaci6n de los nifios pre - escolares de zonas carenciadas, siendo el resultado de una triple integraci6n: con la comunidad para asegurar la inserci6n y participaci6n de las madres de los ninios beneficiarios, con los efectores de atenci6n primaria de la salud situados en la zona para consolidar la atenci6n de estos nifios de 2 a 5 afios de edad con una perspectiva totalizadora, y una integraci6n - no menos importante - de las diversas jurisdicciones institucionales (Ministerios o Secretarias de Educaci6n, Salud, Bienestar Social, de la Mujer, Minoridad, etc.) que tuviesen acciones y / o atribuciones en las provincias y municipios en los que se implementarian los subproyectos Promin, para asegurar un soporte institucional y garantizar la sustentabilidad. Esta estrategia debia asegurar el marco general en el que la tarea especifica del CDI, (promover el desarrollo psicosocial de los pre - escolares, en base al juego, la capacidad expresiva, el lenguaje afectivo - social, intelectual y motriz), pudiera desarrollarse exitosamente a trav6s de las Promotoras Educativas Comunitarias ( mujeres de la propia comunidad especial y permanentemente capacitadas). 12. Debe recordarse, por otro lado que al momento de la formulaci6n y aun en el inicio de los primeros sub - proyectos Promin, no estaban presentes en el horizonte educativo, los efectos de la Ley Federal de Educaci6n y sus disposiciones incorporando a la - 22 -  ensefianza obligatoria a los nifios de 5 anios, indudablemente este y otros factores end6genos al propio Promin y las articulaciones politico - institucionales locales, condicionaron negativamente en cada uno de los subproyectos la consecuci6n de los objetivos propuestos para esta area. 13. En 1997, el componente de desarrollo infantil desarroll6 un instrumento evaluativo que aplicado a 14 .949 concurrentes a los CDI, demostr6 resultados muy positivos en el desarrollo de los nifios bajo programa midiendo con criterios cuantitativos cuatro areas del desarrollo infantil: afectivo - social; lenguaje verbal; motriz; e intelectual. 14. Por otro lado en el propio Promin I, debieran desgiosarse los logros y deficiencias del componente de desarrollo infantil ya que como perspectiva novedosa en el campo de las politicas sociales en la Argentina, merece un anAlisis pormenorizado. 15. El Subproyecto realizado en el Gran Mendoza: la formulaci6n del Promin en la dimensi6n de desarrollo infantil, se integr6 a las politicas sociales de la provincia, permitiendo ampliar la cobertura y mejorar la calidad de los servicios. Esto ultimo se verifica en los resultados obtenidos a partir de la aplicaci6n del instrumento de seguimiento del desarrollo psicosocial del nifno, en el cual casi el 80 % se ubica en las categorias Muy Bueno y Bueno. Actualmente se esta atendiendo al 75% de la poblaci6n infantil prevista, mientras que el 15% faltante depende de la incorporaci6n de nuevo RRHH. Es de sefialar que se ha profundizado sustancialmente la articulaci6n entre Acci6n Social y Educaci6n. 16. Otro caso lo constituye el Subproyecto Rosario: durante el desarrollo del proyecto, la Municipalidad de Rosario tom6 como programa de gobierno, la atenci6n de los nifnos menores de 6 ainos adoptando los objetivos del Promin, los que con algunas modificaciones a la propuesta original, continian siendo vigentes. Se ha fortalecido la articulaci6n con los centros de Salud - en el 80% de los CDI -, lograndose una ampliaci6n de la cobertura bajo control inicial. En los Jardines de Infantes provinciales, el modelo incorpor6 positivamente a las Promotoras Educativas Comunitarias que adoptaron funciones de articulaci6n con la comunidad. 17. En el caso de Florencio Varela: a partir de la implementaci6n del Programa, se acentuo el compromiso de las mujeres que estaban a cargo de los nifios en los CDI que originalmente eran comedores, lo que se tradujo en la constituci6n de la "Liga de Mujeres Varelenses" (organizaci6n no gubemrnamental local). Como producto de la capacitaci6n, mejor6 sustantivamente la calidad de la atenci6n integral de los ninos, lo que se evidenci6 en los resultados de la ficha de Seguimiento que fueron de los mejores obtenidos (94% de los ninios se ubic6 en las categorias Muy Bueno y Bueno). A pesar de estos resultados, la falta de apoyo politico-institucional por parte del Municipio, result6 en un bajo nivel de sustentabilidad. La calificaci6n de los componentes del programa - 23 -  18. En el examen del "Logro del objetivo y rendimientos" (Pto. D.), se analizan los diversos resultados a los que se considera en el texto del ICR, "en cierto modo contradictorios". Los aspectos referidos a infraestructura, se consideran como "mejoras importantes", en tanto que la operaci6n de los servicios de salud se evaluan como mejoras pero "en menor grado" con poca seguridad en cuanto a su sustentabilidad institucional o financiera y se afirman "pocas evidencias del impacto sobre los resultados del desarrollo matemo infantil". 19. En este sentido se califica como satisfactoria la operaci6n de obra civil en centros de salud y matemidades, medianamente satisfactoria la operaci6n de los servicios correspondientes brindados a la poblaci6n y respecto al area de desarrollo infantil se ofrece igual calificaci6n en terminos de ejecuci6n fisica (obra civil y equipamiento), " marginalmente satisfactorio" el desempefio del area institucional del desarrollo infantil, e insatisfactoria en general todo lo referente al fortalecimiento institucional entendido como la mejoria de la capacidad de los gobiemos locales (de provincias y municipios). A nuestro entender y en funci6n de lo expuesto, es satisfactoria la gesti6n de obra civil y equipamiento de ambos componentes (salud y desarrollo infantil), medianamente satisfactoria la operatoria de salud y desarrollo infantil y marginalmente satisfactoria la referida a fortalecimiento institucional. Los factores que incidieron en la implementaci6n del Promin I 20. En cuanto a los factores que "afectaron la implementaci6n y el resultado" en el proyecto de ICR se encuentra un amplio abanico de causas, desde las extemas (atribuibles a la situaci6n socio-econ6mica y su evoluci6n) y otros resultado de las responsabilidades compartidas por los diversos actores implicados en el proyecto. 21. En nuestra opini6n esta visi6n critica contenida en los puntos C y D, debiera completarse con los siguientes elementos: a lo largo de la ejecuci6n del proyecto, las caracteristicas de la planificaci6n estrategica destinada a procurar soluciones a la situaci6n de la poblaci6n matemo - infantil carenciada, que sign6 la formulacion original del Promin, se fue diluyendo por una hiper - politizaci6n de las acciones desarrolladas, que respondi6 en no pocos casos, a las necesidades politicas inmediatas de los gobiemos provinciales y municipales y a la incapacidad de la conducci6n de la UCP de diferenciar estas necesidades clientelisticas de los prop6sitos legitimos e inicialmente acordados del programa. 22. Articulado con esta condici6n, contribuy6 sinergicamente a entorpecer la operatoria, el abandono o sustituci6n de los criterios de seguimiento y evaluaci6n del desempenio de cada subproyecto y del conjunto del Promin (incluida la propia gesti6n central) habiendose previsto un sistema eficiente de informaci6n para la toma de decisiones, el que se remplaz6 por diversas metodologias de control que no constituyeron una base apta para instaurar un sistema de gerenciamiento capaz de encausar eficaz y eficientemente las acciones en el logro de los resultados propuestos y de revisar en el desarrollo de los procesos los objetivos puntuales de cada area sustantiva. -24 -  23. Esta situaci6n negativa perjudic6 incluso el control presupuestario, tanto en la aplicaci6n de los fondos en los subproyectos, como en el compromiso con nuevas inversiones adquiriendo compromisos que avanzaron - como en el caso del Promin II - por encima de los limites del pr6stamo originalmente otorgado por el BIRF. A modo de sintesis 24. Un aspecto fundamental a considerarse en la operatoria del programa y su disociaci6n con los objetivos originales fue el trastocamiento que se produjo desde el inicio de su puesta en marcha. En efecto, las inversiones en obra civil y equipamiento se consideraron en la formulaci6n como una forma de apoyo al cambio de modelo de atenci6n en salud y al desarrollo de la propuesta de CDI, los que claramente estuvieron enunciados como el objetivo principal a alcanzar. 25. Desde el comienzo de las actividades en el Promin I se privilegi6, en cambio, la inversi6n fisica en tanto que en los hechos el resto de los procesos pasaron a tener una consideraci6n secundaria, mas alla de la voluntad de muchos de los actores involucrados. A esto debe sumarse las presiones ejercidas para lograr el cumplimiento de la curva de desembolsos prevista y cuyo cumplimiento s6lo era posible con un ritmo de ejecuci6n de la obra fisica que no respetaba los necesarios procesos de transformaci6n politico / tecnico e institucional. Esto explica el desempefno disimil de los distintos componentes, y relativiza el "exito" logrado en el rubro infraestructura. 26. Indudablemente buena parte de los errores y aciertos que condicionaron la ejecucion y resultados del programa, no pueden desvincularse de la marcha de la situaci6n socio - econ6mica de la Argentina, la que desde su formulaci6n hasta su conclusi6n tuvo un sentido regresivo al aumentar los niveles relativos de pobreza y exclusi6n, afectando al conjunto de la politica social. En las diversas jurisdicciones provinciales y municipales, las necesidades de enfrentar el agravamiento de la crisis social, entendida a comienzos de los 90' como temporaria, repercuti6 transformando en practicamente insustentables la mayoria de los compromisos asumidos por las mismas en los convenios suscritos como marco del inicio de cada subproyecto. (b) Cofinanciers: (c) Other partners (NGOs/private sector): - 25 -  10. Additional Information The Implementation Completion Report (ICR) Team consisted of - Ruth Levine (Task Team Leader) - Evangeline Javier - Juan Pablo Uribe (Health Specialist) - Marian Kaminskis (Team Assistant) Comments were received from: - Myrna Alexander (Country Director, LCC7C) - Ariel Fiszbein (Country Sector Leader, LCC7C) - Daniel Cotlear (Sr. Health, Nutrition and Population Economist, LCSHD) - Jerker Liljestrand (Lead Health Specialist, HDNHE) - Jean-Jacques de St. Antoine (Former Task Team Leader - Lead Operations Officer, ECSHD) - Marie-Odile Waty (Former Task Team Leader) - Vahe Kazandjian (Monitoring and Evaluation Consultant) - The Borrower (Project Coordination Unit) These conmments are available upon request, or from the project file. -26 -  Annex 1. Key Performance Indicators/Log Frame Matrix Indicator (established in June 1995) Target Latest Comments (established Information in June ____________________________ _ 1995) Obstetric coverage (%) 80 26-73 Varies widely across subprojects; no Obstetric coverage ~~~~~~~~~~project average available. Information from Informe General de Cieffe. Pediatric coverage ( 2 80 55-73 Varies widely across subprojects; no project average available. Information from Infonne General de Cierre. Note that at some point between 1995 and 1998, the target was reduced to 60% coverage. Pediatric coverage of children 0-2 81 No age breakdowns available for years (%) pediatric coverage Pediatric coverage of children 2-5 (%) 80 Post-partum followup (%) 80 No information available Early prenatal care ('captaci6n No target 38-68 Not established as a formal indicator, temprana de embarazadas') set but frequently referred to as a sensitive measure of quality of/access to care "Comedores" that fulfill requirements 83 153 Information does not distinguish for Child Development Center between 'comedores" and "jardines." "Jardines" that fulfill requirements for 105 Child Development Center Relationship Child Development 100 Low Anecdotal information Center-Health Center (%/ linked) Available infrastructure (number) 464 434 Medications delivered (number) 853,385 No information available. Available human resources (number of 704 No information available. persons) Food delivered (tons) 4,510 Training workshops (number) 403 No information available on number of training workshops. However, reportedly 9,000 people and 300" training supervisors" (supervisores capacitantes) were trained by October 1999 under combined PROMIN I and II. Communication campaigns (number) 75 No information available. Loan funds disbursed (million) 100 100 National studies contracted and 4 0 terminated 1. Obstetric Coverage is defined as: A) No of pregnant women receiving prenatal care B) N