|1. Project Data:
ICR Review Date Posted:
|Ar-provincial Maternal-child Health Investment Project (1st. Phase Apl)
Project Costs(US $M)
Loan/Credit (US $M)
Sector, Major Sect.:
|: Central government administration, Sub-national government administration, Compulsory health finance, Health, Other social services
Cofinancing (US $M)
|Health system performance (25% - P)
Child health (25% - P)
Population and reproductive health (24% - P)
Social risk mitigation (13% - S)
Indigenous peoples (13% - S)
Board Approval (FY)
||ICR Review Coordinator:
|Pia Helene Schneider
||George T. K. Pitman
||IEG ICR Review 1
|2. Project Objectives and Components:|
a. Objectives:This was the first phase of a three-phased APL. The overall objective of the ten-year APL program is identical with the objective of the APL1, with the exception of geographic targeting. The APL1 includes 9 provinces, whereas the full APL program is nationwide (PAD p.8)
The Legal Agreement states the development objective of the APL1 as “to contribute to the reduction of the infant and maternal mortality rate in the Borrower’s territory, as well as to introduce changes in the incentive framework of health care providers in the Borrower’s Participating Provinces, through the implementation of the MCHIP”.
The PAD (p.4 and 36) describes the main objective of the APL1 as “(i) to halt recent increases in the national rate of infant mortality (baseline at a national average of 16.8 per 1000 live births, and a NOA and NEA average of 25 per 1000) and then reduce it by at least 20% at the national level and at least 30% in the participating northern provinces over a period of 10 years, and (ii) change the dynamic of financing and providing health care services at the provincial level”.
The PAD objective and performance indicators do not mention maternal mortality reduction. Therefore, the ICR Review uses the DPO as stated in the PAD which is congruent with the results framework. The ICR used the same approach.
b. Were the project objectives/key associated outcome targets revised during implementation?
c. Components (or Key Conditions in the case if Adjustment Loans):
I. Implementation of the Maternal-Child Health Insurance Plan Program (MCHIP) (appraisal estimate US$112.1 million, actual US$113.9 million). This component included:
- Capitation payment based on number of MCHIP beneficiaries enrolled
- Medical equipment for participating health facilities
- Technical assistance and training for provincial Ministries of Health to manage MCHIP
- Training of health care providers in delivering MCHIP benefit package
- Information systems for providers and provinces to monitor implementation
II. Strengthening national and Provincial Ministries of Health Stewardship (appraisal estimate US$6.5 million, actual US$5.9 million). This component included:
- Reorganizing the MSN‘s and PHM‘s mandates, staffing and relationships
- Improving epidemiological information, financial and human resource management systems
- Streamlining the regulatory and planning capacity of MSN and its dependent public health program units
- Conducting studies essential for MSN policy formulation
- Preparing Phase 2 of APL.
III. Communication and Community Outreach (appraisal estimate US$4.2 million, actual US$2.9 million). This component included:
- Dissemination of detailed information about program among major stakeholders
- Community outreach to increase participation of target population (e.g. information campaigns adapted to language and cultural needs of indigenous population)
IV. Program Monitoring, Evaluation and Auditing Systems (appraisal estimate US$3.9 million, actual US$6.6 million). This component included:
- Information Technology (IT) to upgrade the monitoring of health provider performance, aggregation and reporting of information
- Concurrent auditing of provider and provincial information for results based payment
- Evaluation activities (e.g. baseline, mid-term and end-of-project impact evaluation)
V. Project Management and Administration (appraisal estimate US$1.4 million, actual US$1.9 million). This component financed the National project implementation unit (PMU) and the nine Provincial PMUs.
d. Comments on Project Cost, Financing, Borrower Contribution, and Dates
- The APL in the total IBRD loan amount of US$435 million is to be implemented over ten years (PAD p.5). The PAD indicates an IBRD amount of US$135.8 million for APL1; followed by US$149.2 for APL2; and US$150 million for APL3.
- The APL1 disbursed 98.6 percent of the appraised amount. Per request of the Government, US$1.57 million were cancelled due to misprocurement.
- The borrower co-financed the program through the federal and provincial government budgets in the estimated amount of at least US$154.1 million (PAD).
- Originally the 9 provinces agreed to co-finance 60% of the capitation amount to MCHIP. This share was reduced to 30% and delayed. Another project (H1N1) financed medical equipment originally planned under this APL1.
- First Loan Amendment on July 7, 2008: to (i) within Component I re-allocate funds from medical equipment to capitation payments, and expand MCHIP benefit package, and (ii) maintain 100% national co-financing of capitation payment until Dec 2008 and postpone start of 60% provincial co-financing to January 2009.
- Second Loan Amendment on Oct 27, 2009: The APL1 closing date was extended by 7 months from the original closing date of Dec 31, 2009 to July 31, 2010. The reason for the extension was initial delays in MCHIP enrollment by beneficiaries, based on which the APL1 funds were disbursed to the Government budget. Provincial co-financing was reduced from 60% to 30% of the capitation amount.
|3. Relevance of Objectives & Design:|
Objectives - Substantial. Reducing infant mortality and changing the dynamic of financing and providing health care services at the provincial level are relevant in the nine Northern Provinces, given their relatively higher poverty and MDG mortality rates, and resource constraints for basic health care services. While several factors influence infant mortality rates in addition to basic medical care, adding this indicator focuses the attention of policy makers (and subsequent public finances) to MDGs; however, it is difficult to establish any direct impact of the APL1 on mortality as many other factors affect infant mortality rates. The CAS (2004) overall objective was to help reduce the extent and severity of poverty in Argentina after the crisis. The APL development objectives were relevant to the CAS both at appraisal and currently (CPS 2010-2012). The latter stresses a continued focus on strengthening provincial health systems through the expansion of the MCHIP, and concurrent audits to support the system's fiduciary performance and transparency. Changing the health financing mechanisms with the introduction of MCHIP remains highly relevant as it provides essential information to the federal government and provinces on the use of health funds that is used to set financial incentives to providers and provinces to improve care in line with standard treatment protocols.
Relevance of Design - High. The design was highly relevant and innovative to achieve the DO. A ten-year APL program helps prioritizing the MCHIP first to the poorest regions while preparing the remaining provinces for the scale up. The design incorporates lessons learned from past projects and an ESW on health financing reforms. The four technical components embrace a system-approach and cover activities (e.g. patient-level data collection and audits) often neglected in projects. The design included innovative parts with conditioned disbursement to the Government budget based on the number of beneficiaries enrolled in MCHIP, "tracer" results-linked capitation transfers to provinces and substantial investment in patient-level data collection and evaluation to link payments to service delivery. The results framework reported relevant key indicators to assess progress. In addition, the 9 provinces measure monthly the number of beneficiaries enrolled in MCHIP for the capitation payment and quarterly the 10 "tracer" health service indicators to assess treatment compliance with standardized protocols. Results are used to adjust the fiscal transfer to provinces thereby setting a financial incentive to policy makers to enable providers in better service provision. The design thus managed to institutionalize the M&E results framework into the country's fiscal transfer system thereby strengthening overall system governance.
|4. Achievement of Objectives (Efficacy) :|
1. To halt recent increases in the national rate of infant mortality (IMR) and then reduce it by at least 20% at the national level and at least 30% in the participating northern provinces over 10 years - Modest
Note the PAD was written in 2004 and referred to 2003 baselines, however, the APL1 became effective in Nov 2004, thus 2005 will be taken as baseline for comparison in this ICR-Review. By June 2005, the MCHIP had about 30% of the target population enrolled, and compliance with tracer indicators were still very low (e.g. well-child visits (10%), APGAR score (3.7%) etc.). The IMR decrease before 2005 cannot be attributed to the APL1.
- Infant mortality rate (IMR) decreased nationwide from 13.5 in 2005 to 12.1 in 2009 (9% reduction in 4 years could possibly reach target of 20% reduction over 10 years).
- IMR in NOA and NEA decreased from 16.7 in 2005 to 14.6 in 2009 (12.6% reduction in 4 years is not on track with target of 30% reduction over 10 years).
While IMR is an important objective, attributing the impact of MCHIP on IMR is ambiguous. IMR has shown a decreasing trend for at least 20 years nationwide and in comparator countries. Also, average IMR are based on data from MCHIP beneficiaries and non-members, suggesting that various factors have affected the average decrease, not just MCHIP.
Two tracer indicators that are influential for IMR have yielded the following results:
- Early inclusion of pregnant women (<20 week) in prenatal care program increased from an average of 4% in 2005 to 45.4% in April 2010 in all nine provinces (tracer 1)
- Well-child visit rate for children up to 12 months increased from 9.5% in 2007 to 31.5% in April 2010.
2. To change the dynamic of financing and providing health care services at the provincial level - High
- All 9 provinces implemented the financing change through capitation financed MCHIP and tracer payment based on 10 tracer results.
- Audits of tracer results and provider reports were conducted as planned and results used to make corrections.
- MCHIP enrollment increased from 0% in 2004 to an average of 84% in 2010 in all 9 provinces. All provinces surpassed target of 50% enrollment.
- The share of providers contracted by MCHIP increased from 0% in 2004 to 71% in 2010 (surpassed target of 50%).
- The percentage of tracer targets met by the nine provinces increased from 0% in 2004 to an average of 74% in 2010, ranging from 54% in Catamarca to 90.5% in Tucuman (surpassed target of 50% for each province).
|5. Efficiency (not applicable to DPLs):|
Overall Efficiency - Substantial
Project funds were implemented efficiently on time with only a six-month project extension. Project spending focused on primary and preventive care services provided in basic health facilities, helping to avert higher cost hospital admissions. The APL1 funded several efficiency-enhancing activities, including better patient level data to improve the adherence to standard treatment protocols.
At appraisal, an economic analysis was conducted, estimating the project’s net present value at US$ 670 million with a rate of return of about 18.1% over ten years.
The ICR estimated a substantially higher rate of return of 31.6% and a benefits/cost ratio of about 2 over 6 years. This result is not plausible considering that the ICR estimated is based on a lower reduction in the infant mortality rate than the reduction estimated at appraisal.
a. If available, enter the Economic Rate of Return (ERR)/Financial Rate of Return at appraisal and the re-estimated value at evaluation:
* Refers to percent of total project cost for which ERR/FRR was calculated