The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Program Information Documents (PID) Appraisal Stage | Date Prepared/Updated: 19-Apr-2023 | Report No: PIDA275544 Apr 03, 2023 Page 1 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) BASIC INFORMATION OPS_TABLE_BASIC_DATA A. Basic Program Data Country Project ID Program Name Parent Project ID (if any) Argentina P179595 Program for Effective Universal Health Coverage and National Health System Integration Region Estimated Appraisal Date Estimated Board Date Practice Area (Lead) LATIN AMERICA AND CARIBBEAN 20-Apr-2023 16-Jun-2023 Health, Nutrition & Population Financing Instrument Borrower(s) Implementing Agency Program-for-Results Financing Argentine Republic National Ministry of Health Proposed Program Development Objective(s) To support improvements in: (a) the equitable and effective coverage to public health services, and (b) the efficiency of the health system. COST & FINANCING SUMMARY (USD Millions) Government program Cost 3,072.30 Total Operation Cost 1,713.47 Total Program Cost 1,713.47 Total Financing 1,713.47 Financing Gap 0.00 FINANCING (USD Millions) Total World Bank Group Financing 300.00 World Bank Lending 300.00 Total Government Contribution 1,413.47 Apr 03, 2023 Page 2 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Decision The review did authorize the team to appraise and negotiate B. Introduction and Context Country Context 1. With a gross domestic product (GDP) of US$614 billion, Argentina was the third-largest economy in Latin America in 2022. The country has 2.8 million square kilometers, and its population of about 46 million inhabitants1 is highly urbanized, with 92 percent living in cities. The Buenos Aires Metropolitan Area alone constitutes 33 percent of the national population and generates more than 40 percent of Argentina’s GDP. Argentina is a federal state. Hence, its 23 provinces and the Autonomous City of Buenos Aires preserve their autonomy under the national government. 2. The middle class has historically been large and strong, with social indicators generally above the regional average; however, persistent social inequalities, economic volatility, and underinvestment have limited the country’s development. The rate of urban poverty reached 39.2 percent in the second semester of 2022, and 8.1 percent of Argentines live in extreme poverty. Childhood poverty, for those under 15 years old, is at 54.2 percent. The high frequency of economic crises in recent decades—the economy has been in recession during 21 of the past 50 years—has resulted in an average annual growth rate of 1.8 percent, well below the world average of 3.6 percent and the region average of 3.2 percent. Decades of underinvestment have led to sizeable gaps in capital stock relative to comparable countries, although capital spending as a percentage of GDP has improved in recent years. Such volatile macroeconomic environment has hindered the country’s ability to reduce poverty rates and infrastructure deficit and increase incomes. 3. The economy recovered from the Coronavirus Disease (COVID-19) crisis at a fast pace, reaching pre-pandemic activity levels by mid-2021. Argentina’s economy grew by 10.4 percent in 2021 and 5.2 percent in 2022, the largest increase in GDP since the 2010-2011 biennium, after the global financial crisis. Higher commodity prices and trading partners’ growth, notably Brazil’s, combined with public investment led to a robust growth recovery in 2021 and the beginning of 2022. However, since 2022 increasing macro imbalances and a more turbulent global context, started to slow down the pace of GDP growth. The Government of Argentina has concluded the process of restructuring its debt in foreign currency (both local and external) with private creditors, significantly improving the maturity profile for the next five to eight years. 4. In March 2022, Argentine authorities reached an agreement with the International Monetary Fund (IMF), on an Extended Fund Facility (EFF) program for a period of 30 months and an amount of US$45 billion, to address the economy’s macroeconomic imbalances and set the basis for sustainable growth. This amount covers the remaining obligations under the 2018 SBA (US$40.5 billion) and provided 1 https://www.censo.gob.ar Apr 03, 2023 Page 3 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) a small net financing support for reserves accumulation (US$4.5 billion). The program sets a gradual fiscal consolidation path toward a zero primary deficit in 2025 (from 3 percent in 2021 to 2.5 percent of GDP in 2022, 1.9 percent in 2023, and 0.9 percent in 2024), a reduction of monetary financing of the deficit (eliminated by 2024), and the framework for monetary policy involving positive real interest rates, as part of a strategy to fight inflation. A staff-level agreement on the fourth review under Argentina’s 30-month EFF arrangement was approved by the IMF Executive Board in March 2023, granting Argentina access to about US$5.3 billion (SDR 4.0 billion). 5. Despite meeting all the performance criteria under the IMF EFF by end-2022, Argentina’s macro- fiscal situation remains challenging. According to the IMF statement, prudent macroeconomic management in the second half of 2022 supported stability and helped secure program targets through end-2022 with some margin. Nevertheless, capital controls and deficit monetization continue to cause a large gap between the official and parallel exchange rates and limit foreign reserve accumulation. Inflation accelerated to historically high levels (102 percent year-over-year, as of February 2023), denting purchasing power. While fiscal targets have been met so far, a still sizable fiscal deficit continues to put pressure on monetary policy, given limited access to capital markets. A severe drought is expected to strongly affect agricultural production in 2023, reducing exports and fiscal revenues while limiting the capacity of the Central Bank to accumulate international reserves. 6. In this context, the government is increasing efforts towards a gradual macroeconomic stabilization program that contains a broad set of economic policies, including measures to rationalize and harmonize the current complex exchange rate regime. To reduce the monetary financing of the fiscal deficit and the associated persistent and high inflation, the government has adopted measures to reduce the cost of subsidies and improve their targeting, especially in the costly energy sector. In addition, it is taking steps to start addressing the multiple currency practices and strengthening the trade balance, while promoting reserve accumulation. Specific initiatives, adopted in early April 2023, include a unified set of exchange rates for key exports and imports that reduces the gap with the parallel exchange rate; a rationalization of the tax treatments related to the imports of goods and services (which amount to de facto multiple exchange rates); and improving the ability of the customs administration to supervise and control the over invoicing of trade and other related distortions. In addition to addressing the urgent need for reserve accumulation, these measures should help pave the way for the eventual easing of foreign exchange controls. 7. Argentina is also at high-risk of climate-related hazards. Notably, floods are the most frequent climate-related hazard representing 52 percent of the total natural hazards in the country. Approximately 14.2 million people live in flood-prone areas, with most of the exposed population located in the Greater Buenos Aires, Pampas, and Gran Chaco regions, accounting for 65 percent of the Argentine population.2 Argentina suffers an average of US$1.08 billion each year in direct asset losses and US$3 billion in welfare losses due to floods.3 From 2000 to 2011, flooding events affected 5.5 million people. The country is also 2 Ministerio de Salud, Argentina. Clima y Salud en Argentina: Diagnóstico de situación 2019. Extracted from: https://bancos.salud.gob.ar/recurso/clima-y-salud-en-la-argentina-diagnostico-de-situacion-2019 3 Hallegatte, Stephane; Vogt-Schilb, Adrien; Bangalore, Mook; Rozenberg, Julie. 2017. Unbreakable: Building the Resilience of the Poor in the Face of Natural Disasters. Climate Change and Development. Washington, DC: WB. https://openknowledge.worldbank.org/handle/10986/25335; Hallegatte, Stephane; Rentschler, Jun; Rozenberg, Julie. 2019. Lifelines: The Resilient Infrastructure Opportunity. Sustainable Infrastructure. Washington, DC: WB. Apr 03, 2023 Page 4 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) vulnerable to wildfires, storms, landslides, droughts, and extreme temperatures.4 Droughts have affected agricultural production in the country, impacting crops such as wheat, and heat waves have become more frequent, affecting mainly urban populations due to the heat island effect. Additionally, increased aridity and drought events have adversely affected the country. The central region, which includes the core crop and livestock areas, is particularly vulnerable to drought impacts. From 2006 to 2011, major drought events caused approximately US$4 billion in losses and affected one million Argentines. Overall, Argentina ranks amongst the ten emerging economies most vulnerable to climate change5. 8. Projected climate patterns show a temperature increase of +1.6 C by the 2050s, and by 3.3 C by the end of the century under a high emissions scenario (RCP 8.5.), worsening climate extremes. 6 The southernmost part of the country (the Patagonian region) is expected to experience the most significant increase from current temperatures, while the northwest regions will experience the warmest temperatures. Sectoral and Institutional Context 9. Argentina’s health outcomes have improved significantly in the past decades, but considerable subnational inequalities persist. Improvements in health outcomes are the result of increased access to essential health services, especially maternal and child services and, to a more limited extent, services for non-communicable diseases (NCDs). Between 2005 and 2018, the percentage of women aged 50 to 70 years receiving a mammography rose from 46 percent to 66 percent, and the percentage of adults having a high blood pressure control test rose from 79 percent to 84 percent.7 Accordingly, life expectancy rose from 75 years (2015) to 77 years (2019) before the COVID-19 pandemic erased previous gains and life expectancy fell again to 76 (2020).8 However, health outcomes vary substantially across provinces (Figure 1). In poorer regions of the country (namely the northeastern and northwestern), infant and maternal mortality rates remain high relative to other areas. Also, the overall adjusted mortality rate is higher in the Northern provinces. https://openknowledge.worldbank.org/handle/10986/31805. 4 Emergency Events Database, https://www.emdat.be/. 5 World Bank (2018). ARGENTINA: Escaping crises, sustaining growth, sharing prosperity. Extracted from: https://documents1.worldbank.org/curated/en/696121537806645724/pdf/Argentina-Escaping-Crises-Sustaining- Growth-Sharing-Prosperity.pdf 6 https://climateknowledgeportal.worldbank.org/sites/default/files/2021-06/15850-WB_Argentina%20Country%20Profile- WEB%20%281%29.pdf 7 Data source: National Risk Factor Surveys from 2005 and 2018 (the latest available edition). 8 Source: World Bank World Development Indicators. Apr 03, 2023 Page 5 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Figure 1. Infant, Maternal and Overall Adjusted Mortality Rates across Provinces (2020) Source: National Directorate of Health Statistics and Information (DEIS), National Ministry of Health. https://www.argentina.gob.ar/salud/deis/reporte-interactivo 10. Despite the improvements, health indicators are still worse than in countries with similar income and health spending levels. Comparable countries such as Costa Rica and Chile fare better in terms of key health outcomes, including those that are good indicators of health system effectiveness, such as Infant Mortality Rate (IMR) and age-standardized mortality rate related to NCDs (Table 1). Table 1. Health Outcomes and Expenditure in Argentina and Comparator Countries (2018) Argentina Chile Colombia Costa Rica Uruguay Immunization, DPT vaccine (percentage of children 86 95 92 94 91 ages 12-23 months) Mortality from cardiovascular diseases (CVD), cancer, diabetes, or chronic respiratory diseases 16 10 10 10 17 (CRD) between exact ages 30 and 70 (percentage) IMR (per 1,000 live births) 9 6 12 8 7 Life expectancy at birth, total (years) 77 80 77 80 78 GDP per capita, based on purchasing power parity 23,306 24,740 14,866 20,994 23,588 (PPP) (current international $) Current Health Expenditure (CHE) as GDP 10 9 8 8 9 percentage CHE per Capita in PPP 1,990 2,306 1,155 1,337 2,169 Source: World Bank World Development Indicators and World Health Organization Global Health Expenditure Database. 11. Further improving health outcomes requires a more equitable coverage of health services. Health insurance coverage in Argentina is linked to participation in the formal labor market. About two thirds of the population has social or private health insurance and receives health services from private Apr 03, 2023 Page 6 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) providers (subject to considerable fluctuations depending on the economic conjuncture).9 The non- contributory subsystem offers services to all Argentines, but it is mainly used by people without formal employment and thus without social security or private insurance coverage. This population group is more likely to be poor10 and has lower coverage of essential health services, so is less likely to receive essential health services such as NCD screening and treatment services (Table 2). Table 2. Differences in Service Provision across Subsystems and Provinces (2018 Screening/Preventive Test Private/Social Only Public Health Insurance Coverage Colon Cancer Screening in last two years 35.2 16.8 A Mammography in last two years 70.7 46.4 A PAP in last two years 76.3 58.4 At least one Cholesterol Test 87.7 62.6 At least one Blood Sugar Level Test 85.9 64.8 High blood pressure control 89.6 73.1 Received any treatment for controlling diabetes or high blood glucose 56.7 41.9 Received any treatment for controlling cholesterol 49.3 31.5 Received any treatment for controlling high blood pressure 60.9 31.1 Source: National Risk Factor Survey (2018) Note: Age & Gender groups for different tests/screenings as defined in Clinical Guidelines. 12. The combined effects of the COVID-19 pandemic and the economic recession exacerbated the pressure on the public subsystem to provide access to quality services, as public service provision was disrupted by lockdowns and social distancing, while the uninsured population grew. The population relying exclusively on the public subsystem accounted for 43 percent of the population in December 2022, compared to 36 percent in December 2019.11 At the same time, the COVID-19 pandemic and related response measures (i.e., lockdowns and the minimization of social contacts) disrupted the provision of essential health services. As a result, general outpatient consultations dropped 26 percent during the first quarter of 2020 and diabetes blood tests and breast cancer screenings dropped 39 and 63 percent respectively in 2020, compared to the average coverage of 2018-2019.12 The reduction in immunization coverage is also a growing concern: in 2020, there was an average decrease of ten percentage points in national vaccination coverage for all vaccines compared to the previous year, with immunization for school-aged children and adolescents being the most affected.13 The coverage of children with measles, mumps, and rubella (MMR) at school entry decreased 12.5 percentage points between 2019-2020 (84.2 vs. 71.7).14 Mental health has also become a major source of disability that was exacerbated by the pandemic, with depressive and anxiety disorders representing two of the top five leading causes of Years Lost due to Disability (YLD);15 highlighting an urgent need for the public delivery network to provide quality 9 Source: Permanent Household Survey. 2° quarterly 2022. INDEC. 10 Around 40 percent of the total population relies exclusively on the public subsystem, including almost 60 percent of the poor and about 75 percent of the extremely poor (according to the Permanent Household Survey of 2022). 11 Source: Sumar Program 12 Information provided by Sumar and Proteger Programs. 13 https://bancos.salud.gob.ar/recurso/informe-sobre-el-impacto-de-la-pandemia-sars-cov-2-en-las-coberturas-nacionales-de 14 https://bancos.salud.gob.ar/recurso/informe-sobre-el-impacto-de-la-pandemia-sars-cov-2-en-las-coberturas-nacionales-de 15 Institute for health Metrics and Evaluation (2019) Apr 03, 2023 Page 7 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) mental health services. 13. The COVID-19 pandemic also put in evidence the need to increase access to new and improved services for women, particularly those related to the prevention, detection, and treatment of domestic violence. According to United Nations data released in September 2020, lockdowns led to a 25 percent increase in complaints or calls to report domestic abuse in Argentina. Data from the latest (2020) Survey on Prevalence of Gender-based Violence (GBV) against women in Argentina16,17 shows that almost half(45 percent) of women between 18 and 65 years old have suffered some type of intimate-partner violence (IPV) and an additional 12 percent experienced sexual violence by someone other than an intimate partner.18 Nevertheless, about 31.7 percent indicated that they were not aware of any GBV related service or support system. Thus, there is an urgent need to improve access to, and quality of, these services. 14. Improving health outcomes requires not only improving equitable coverage of services, but also improving the quality of the health services in the public delivery network. The concept of effective coverage (timely access and utilization with quality standards) of health services refers to the coverage of services of sufficient quality.19 Despite improvements over time, several weaknesses remain in the quality-of-service provision, particularly for NCD prevention and control, including mental health, as not all eligible population groups receive the relevant and necessary screening and control services for timely detection and care. Although breast cancer is the cause of nearly 10 percent of all deaths in Argentina20, and continues to be the leading cause of cancer-related deaths for women, 34 percent of women between 50 and 70 years of age did not have a mammography within the last two years, and this percentage increases for those women with exclusively public coverage21. Effective disease control strategies for chronic conditions such as breast cancer focus not only on early detection, but also on ensuring that women with suspicious findings have access to a diagnostic study and, if cancer is confirmed, to timely and effective treatment. Similarly, cancer is the fourth leading cause of mortality in children under four years of age, with leukemia being the most frequent cancer. In comparison with high-income countries, the 5-year survival rate in Argentina is much lower (67.6 percent vs 80 percent or higher).22 According to the National Cancer Institute (INC), this difference could be explained, in part, by late diagnoses and lack of adequate follow-up care. Cancer in children is of a low incidence but significantly impacts mortality and morbidity in the age group and merits specific diagnostic and therapeutic strategies.23 Ensuring the 16 The MMGyD, together with the Spotlight Initiative, developed the Survey on the Prevalence of Violence against Women, which addresses the occurrence of different acts of violence throughout the lives of the women interviewed. A total of 12,152 women between 18 and 65 years of age were interviewed, living in private homes in 26 localities in 12 provinces. In this first survey, priority was given to the survey on gender-based domestic violence. 17 Ministry of Women, Gender, and diversity: 2020 Survey on Prevalence of Gender-based Violence against Women: https://www.argentina.gob.ar/sites/default/files/2022/08/encuesta_de_prevalencia_violencia.pdf 18 UN WOMEN Global Database on violence against women https://evaw-global- database.unwomen.org/en/countries/americas/argentina#3 19 https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30104-2/fulltext#back-bib2 20 Per the INC, 2022. Based on National Directorate of Health Statistics and Information (DEIS) from the National Ministry of Health, 5,820 women died from breast cancer in 2021. Breast cancer was the fourth cancer-related cause of mortality nationally (9.6 percent of all deaths) and first among women (15.9 cases for every 100,000 women). 21 2018 National Risk Factor Survey. 22 Macerira, Suarez, Diaz. Integración Funcional del Sistema de Salud. Red Oncopediátrica en Argentina: Antecedentes, capacidades y desafíos. Reporte No: AUS0003229 23 Idem. Apr 03, 2023 Page 8 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) provision of quality care for these conditions requires continuity of care, both across time and across levels of providers. 15. The fragmentation of the Argentine health system causes major challenges to ensure the equitable and effective coverage of health services, their quality, and the efficient use of resources. This fragmentation is not only related to the labor market status of the population, but also to the federal nature of the government. The public service delivery network, the main provider of health care for households without health insurance, is decentralized. The provinces are responsible for service delivery and in a few cases, such as Buenos Aires, Santa Fe, and Cordoba, the municipalities oversee Primary Health Care (PHC). This multidimensional fragmentation is not only linked to the non-contributory subsystem with its 24 provincial ministries of health, but also to the contributory one, which includes about 300 national social security institutions, as well as several provincial ones. Finally, there is also a private insurance market covering a small percentage of the population. This complex structure of the Argentina health system limits: (i) Equitable and effective coverage of health services. Currently, the resources available per beneficiary, the type of provider, and the benefit plans differ across subsystems. Not surprisingly, the coverage of quality essential health services also differs across subsystems (Table 2), and across provinces (Figure 1). (ii) The quality of the care provided. Quality health services require a high degree of coordination across and within levels of care; particularly services for the management of NCDs. Often providers belong to different jurisdictions or institutions, making this coordination challenging. Even within the same level of government or governance structure, coordination among providers is often difficult due to weaknesses in information systems; lack of clear roles and responsibilities; and mismatched laws, funding, regulations, and training.24 The fragmentation in the public delivery network has generated challenges in the development of well-functioning and integrated health networks that can ensure the continuity of care for all patients exclusively covered by the public system. For instance, referrals and counter-referrals remain mostly informal and based on physicians/health personnel relationships with the referral center. This situation not only limits the quality of the services provided, but also causes the duplication of services as well as gaps in services provision. For high complexity conditions, such as congenital cardiopathies or pediatric cancers, this fragmentation generates even larger barriers for quality care, since an effective network beyond the provincial level (e.g., a regional or even national integrated network) is needed. (iii) Efficiency gains. The general health system’s fragmentation is reflected in i) fragmented procurement processes which limit economies of scales; ii) fragmented information systems that prevent the efficient management and sharing of crucial information and might generate errors in provision (e.g., adverse drug effects); and iii) different and unaligned benefit packages across subsystems that not only thwart equitable access, but also decrease allocational efficiency as they lack clear prioritization mechanisms. 16. The National Ministry of Health (MSN, for its Spanish acronym) has made significant and 24http://www.metaballcreative.com/INT001/pdf/HCPolicySupplement.pdf#page=14; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2653966/ Apr 03, 2023 Page 9 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) successful efforts to improve effective and equitable coverage of health services through flagship programs that received the support of the World Bank (WB) and other development partners. Programs such as Nacer/Sumar Program (Box 1) have improved effective coverage of essential health services for the population without health insurance coverage. As widely documented,25 these Bank-financed operations have been recognized for their innovative design features and their substantial achievements in terms of relevance, efficacy, and efficiency in the provision of quality health care services for the uninsured. Particularly noteworthy in the context of the pandemic, the Sumar Program contributed to strengthening Argentina's public health care system. Indeed, the number of people with effective health coverage26 under this program increased by about 20 percent, from around five million people before the pandemic to six million in mid-2022. Other programs such as Proteger (Box 1) have established an enabling environment to improve the quality of the NCD screening, prevention, and control services. These programs, however, have often used different mechanisms to generate incentives between the federal government and the provinces. These mechanisms were not always integrated in the government systems, thus the need to revise and ensure the sustainability of these programs, now Government policies, and the positive results they have been instrumental in achieving. 25 See, among others: (i) Cortes, R (2013) “Argentina - Increasing Utilization of Health Care Services among the Uninsured Population: The Plan Nacer Program�. Unico’s Studies, January 2013; (ii) Gertler, P., Giovagnoli, P., and Martinez, S. (2014), Rewarding Performance to Enable a Healthy Start: e Impact of Plan Nacer on Birth Outcomes of Babies Born into Poverty, Policy Research Working Paper 6884, World Bank; (iii) Systematic testing of the impact of potential operational changes. Pablo Celhay, Paul Gertler, Paula Giovagnoli, Christel Vermeersch (2015). Long Run Effects of Temporary Incentives on Medical Care Productivity. NBER working paper No. 21361. (iv) Ortega Nieto, D. and Parida, I. (2015), "How to Ensure Quality Health Care and Coverage of Uninsured Populations: Argentina’s Plan Nacer," Global Delivery Initiative Case Study, September 2015. (v) Zanetta, C. (2020), "The Establishment of Argentina’s Federal Network for the Care of Congenital Heart Defects," Global Delivery Initiative Case Study, September 2020. (vi) The Latin America and Caribbean Regional Operations Services Unit (2020 Volume 15), “Results in Latin American and Caribbean Region�, September 2020. 26 Number of patients that were registered in the Program that received a service included in the benefit package during a year. Apr 03, 2023 Page 10 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Box 1. The Sumar and Proteger Programs: Objectives and Design Features The Nacer Plan and the Sumar Programs (supported by a series of Bank-financed Projects* over a period of more than 15 years since Nacer Plan was first launched) have laid the foundation for a national policy that seeks to achieve UHC through a public insurance scheme. The cornerstone of this policy is to reduce inequalities in access to health care services and to increase timely coverage to health care at guaranteed quality standards for the entire population with public health coverage, regardless of where they live or their socioeconomic status. The Sumar program created effective incentives with limited resources (funding from Sumar represents approximately 2.5 percent of the provincial health budget), leading to a benefit package funded by Sumar that has grown to include almost 700 interventions. The design of the Sumar Program is based in the supply of financial support for capitation payments to the Provincial Ministries of Health (MSP) for the provision of cost-effective General Health Interventions (GHIs) included under a Health Benefit Plan to improve coverage to quality health services to the eligible population. Relying on an effective scheme of results-based economic incentives for both provinces and service providers and robust quality-control mechanisms, Sumar has contributed to the incremental development of provincial health insurances, expanding their scope in terms of territorial coverage, beneficiary population subgroups, health services, and service delivery strategies, health information systems and registers and instrumental strategies. The capitation payment functions as an insurance premium and is calculated for the prioritized package of general health services selected based on their cost effectiveness in preventing, treating, or curing diseases that contribute significantly to the burden of disease of the selected population subgroups. The methodology used to determine the capitation payments considers the full actuarial cost for the per capita insurance premium, based on the difference (per person, on average) between: (a) the full cost of service delivery for the prioritized package of health services, assuming all the requisite quality-related protocols are fully adhered to, and (b) the current level of public spending for these services. In addition, the capitation amount includes an “equity� component that is calcul ated as a function of each province’s life expectancy at birth, which is a proxy for the province’s health outcomes. These values (for each province in the latter case) are reviewed and updated periodically. In practice, the maximum value of capitation payment for any province is only attained if the province attains a “perfect score� – i.e., by reaching the maximum targets for all “tracer� indicators. The “tracer� indicators are a set of indicators of provincial performance that have been carefully selected in line with the Project’s goals. Of the maximum value a province could attain, 60 percent would be automatic per eligible person enrolled and with effective coverage, regardless of performance. The remaining share (40 percent) would be adjusted downwards according to provincial performance regarding the tracer indicators. The Health Benefit Plan also includes the coverage of services for selected High�Complexity Diseases (HCDs) supported by a fund financed through a capitation payment based on the total number of eligible enrolled population to the Program that serves as a risk pooling at the national level. In 2010, the MSN started the implementation of this fund to finance the services provided by the Federal Network of Congenital Cardiopathies (RFCC). Today the fund, now called the National Fund for Equity in Health (FONES), also includes a High�Complexity Perinatal Package, with congenital malformations, services for acute myocardial infarction, and COVID -19 treatment. The trajectory of the Sumar Program is remarkable in view of the international evidence on RBF programs and their institutionalization. Internationally, one key bottleneck to scaling up and institutionalizing RBF programs has been found to be related to PFM systems and their ability to scale the performance or result-based payments. In that regard, the development of purchasing capacity within the Ministry in charge of the RBF scheme and the existence of a purchasing unit are key obstacles to the sustainability and continuation of RBF schemes over time. In the case of the Sumar program, major advances in the purchasing capacity of the MSN have been made, but further progress is needed. The Proteger Program aimed to support the implementation of a national and provincial NCD strategy to protect vulnerable populations (those with only public health coverage) against these conditions by ensuring access to quality services while improving health promotion and epidemiological surveillance. Bank-financed support (P133193) specifically contributed to improve the readiness of public health facilities to provide expanded NCD-related services and protect the population against prevalent NCD risk factors (i.e., tobacco, physical inactivity, and unhealthy diets). The Program design had two key innovative features: (a) an integrated approach towards NCDs and their risk factors; and (b) a result- based financing mechanism. One of its main achievements has been to improve the readiness of public health facilities to deliver higher quality NCD-services for vulnerable population groups and expanding the scope of selected services. The Project incorporated a robust system of results-based financial mechanisms that provided incentives to the provinces, health facilities and municipalities for actions aimed at improving prevention and control of NCDs. To this end, the operation supported: (i) the implementation of systematic assessment tools focusing on the delivery of NCD services in PHC facilities with financial incentives provided under a result base mechanism; (ii) the development of provincial plans for an integrated approach toward NCDs detection and treatment and underlying risk factors; and (iii) NCD training to health staff at the provincial level. *P071025, P095515, P106735, P163345, and P174913 Apr 03, 2023 Page 11 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 17. In addition, the MSN has been implementing strategies to improve financial protection as well as financial access to services. According to the National Household Expenditure Surveys 2004-2005 and 2017-2018, there is a 25 percent (from 15 to 11 percentage points) and 39 percent (from 5 to 3 percentage points) reduction in the share of Argentine households that incurred catastrophic health spending,27 using a 10 and 25 percent of total household spending threshold respectively.28 However, due to the highly fragmented and decentralized nature of the health system, there are still many challenges related to multiple funding sources with unclear governance mechanisms and insufficient coordination, resulting in large inefficiencies that reduce the system’s ability to further improve financial protection and access to services. 18. Additional efforts are needed to further improve the equitable and effective coverage for key health services and the overall efficiency of the sector. These include efforts by the MSN to tackle: (a) the remaining inequalities in effective coverage of services; (b) the lack of an integrated and people- centered delivery network, particularly for the care of patients with NCDs and mental health conditions; and (c) the lack of an integrated benefit package to cover all Argentines equally. Finally, and particularly after the COVID-19 pandemic, the MSN also needs to effectively confront emerging and re-emerging challenges related to mental health, climate change, GBV, as well as better integrate gender and diversity considerations into their health care provision. 19. Climate change is posing additional threats and challenges to the ability of the health system to provide access and continuity of care, and its effects –in the form of increased risks of flash or surface flooding, heatwaves, and wind gusts accompanied by precipitation– are already noticeable. Approximately 52 percent of natural disasters in Argentina are floods, accounting for 95 percent of economic losses from natural hazards. These and other climate-related extreme events, such as heatwaves (which have doubled since the 1960) and wildfires, are expected to increase in frequency and severity. These extreme events often result in damages to health care facilities, often disabling them completely. Additionally, climate change increases health risks such as water or vector-borne diseases, such as dengue, with frequent outbreaks during the hot rainy season. Increased temperatures are already yielding an increase in heat-related morbidity and mortality in the country, particularly in Buenos Aires where, during the heatwave on the summer of 2012-2013, there were 1877 excess deaths. More intense droughts and increased temperatures would also create more suitable conditions for more frequent and intense wildfires, causing power outages, leaving millions of Argentines without power, and affecting the functioning of health services particularly those that are ill equipped or in remote areas. s. A changing climate also affects the prevalence of NCDs, with an increase of 13.7 percent of hypertension cases documented during severe heat wave. Other climate sensitive NCDs, such as mental health disorders, have been highlighted as key priority in the country by their National Determined Contributions and their 2019 Climate and Health Country Assessment. In this context, improved preparedness and surveillance is urgently needed. 27 Catastrophic health expenditure is defined as the percentage of households whose out-of-pocket expenditure in health exceeds a certain threshold of their total expenditure. 28 Varco, María José, Campodónico, Inés María, de los Reyes, Laura, Laurenza, Mercedes, & Levcovich, Mónica. (2022). GASTO CATASTRÓFICO Y EMPOBRECEDOR EN SALUD: UN ESTUDIO PARA ARGENTINA. Revista Argentina de Salud Pública, 14, 71. Available at: http://www.scielo.org.ar/scielo.php?script=sci_arttext&pid=S1853-810X2022000100071&lng=es&tlng=es. Apr 03, 2023 Page 12 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 20. Additionally, climate-related hazards increase health inequities, as climate risks affect populations that are already vulnerable, with groups such as the elder, women, infants, and the poor being at higher risk. The factors that affect a population’s vulnerability to climate are often like those that affect health more broadly, therefore improving effective Universal Health Coverage (UHC) in Argentina, can contribute to reducing the impacts of climate on vulnerable groups. Notably, heatwaves impact the elderly, showing that during the summer 2012-2013, the relative risk for people between 60 and 79 years was higher as this group accounted for the majority of heat-related deaths, and the risk of death increased even further for people 80 years and older. Similarly, women are at higher risk than men for heat-related mortality (relative risk 1.58 and 1.34 respectively). Finally, the Organization for Economic Cooperation and Development (OECD) highlights informal urban settlements (“villas�), where residents have more constraints accessing safe water and sanitation services, are also exposed and are more vulnerable to extreme climate events such as floods. 21. Argentina has committed to achieving ambitious emission reduction targets since its first Nationally Determined Contribution (NDC) back in 2016. The country has continuously updated and upgraded the ambition of its Nationally Determined Contributions and during the 2021 Leaders’ Summit on Climate, the country announced its new goal of limiting emissions to 349 MtCOeq by 2030. The latter target represents an increase in ambition of roughly 28 percent since the first commitment announced in the 2016 Nationally Determined Contributions.29 Argentina has built a legal and regulatory scaffolding to respond to the country’s ambitious climate targets, including the climate change mitigation and adaptation mandatory minimum budget law (Ley de Presupuestos Mínimos de Adaptación y Mitigación al Cambio Climático Global) which allows institutions in the country to devote additional resources to the implementation of the country’s Nationally Determined Contributions30. The country also has established an inter-ministerial and interdisciplinary climate change cabinet to lead the preparation of specific plans, including the national climate change response (“Plan Nacional de Respuesta al Cambio Climático�), mitigation (“Plan Nacional de Mitigación�), adaptation (“Plan Nacional de Adaptación�) and sectoral plans (“Planes de Acción Nacionales Sectoriales de Cambio Climático�)31, including a health sector action plan and national program (2021).32,33 The implementation strategy for the plan is still in progress as needs coordination efforts among sectors and among provinces and strong stewardship from the MSN. 22. In response to the sector’s challenges mentioned above and building on its successful experiences, the MSN has adopted the National Integrated Health Plan (NIHP) for 2023-2025.34 Its objectives are to: (a) increase effective and equitable coverage of prioritized quality health services in the public subsystem; (b) improve the integration and continuity of care by strengthening health service networks; (c) support the integration and coordination between the public, private, and social security subsystems (for instance, through the progressive harmonization of the health services packages by 29 Presidencia, Actualización de la meta de emisiones netas de Argentina al 2030 , 2021, available online at: https://unfccc.int/sites/default/files/NDC/2022-05/Actualizacio%CC%81n%20meta%20de%20emisiones%202030.pdf 30 Romero, Ramos & Harari. 31 Ibíd. 32 RESOL-2021-555-APN-MS. Programa nacional de reducción de riesgos para la salud Asociados al cambio climático, and RESOL-2021-2956-APN-MS 33 https://www.argentina.gob.ar/sites/default/files/infoleg/res447-6.pdf 34 Plan Nacional Integrado de Salud 2023 - 2027. Apr 03, 2023 Page 13 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) approving and implementing the newly developed Argentine Integral Health Services Plan (PAISS, for its Spanish acronym) and; (d) promote a more efficient procurement of drugs and health technologies. 23. To support the NIHP, the Government requested WB financing for a Program for Results (PforR) operation, building on successful ongoing Bank-supported initiatives such as the Sumar Program, which has had a remarkable trajectory in view of the international evidence on Results-based Financing (RBF) programs and their institutionalization. The use of financial incentives to strengthen the MSN’s stewardship role in the health system –building upon mechanisms already being implemented under previous and ongoing WB-supported programs35– would be key under the PforR as well and other ongoing programs36 that would serve as basis for the NIHP’s implementation. To this end, the PforR constitutes a cornerstone for the full institutionalization of the above-mentioned programs, as it supports the transition from a program to a national policy that forms part of the national strategic health plan. PforR Program Scope 24. The federal organization and legal framework of Argentina establish that the MSN has fundamentally an oversight, regulatory, and stewardship function over the whole health system. The MSN is also responsible for national-level programs that aim to improve equity and quality in the provision of health services (i.e., childhood immunization, essential drugs, the Sumar Program, the Proteger Program, the Quality program, among others) and for the design and implementation of policies to optimize the system overall. Provinces, through the Provincial Ministries of Health (MSPs), have the primary responsibility for service delivery and financing, as well as for managing government health services. In turn, the municipalities (local level) oversee the execution of national and provincial programs, and in some provinces, like Buenos Aires, Córdoba, and Santa Fe, have responsibility for service delivery and financing. The roles and functions of the MSN include: (a) the formulation and evaluation of health policies, plans, programs and projects; (b) the promotion of healthy habits in the population; (c) the prevention of endemic diseases and NCDs; (d) human resources and talent in the health sector; (e) health surveillance; (f) preparedness and emergency response; (g) climate change strategies related to the health sector; (h) health systems, national records for health, and digital health agenda; (i) the development of clinical guidelines and protocols; and (j) the formulation, adoption, and evaluation of policies related to pharmaceuticals, medical devices and supplies, biomedical technology, and service delivery. The MSN interacts with the provincial health ministries within the framework of Federal Health Council (COFESA). 25. In pursuing its function, the MSN’s NIHP (2023-2025) emerges as a response to structural problems and emerging challenges facing Argentina’s health system and with the general objective of “contributing to the development of an integrated, equitable and sustainable health model, which guarantees the effective coverage to comprehensive health care services�. The specific objectives mentioned in the Government document are to: (a) increase effective and equitable coverage of prioritized health services and care lines, under the criteria of quality, transparency, and efficiency; (b) improve the integration and continuity of care by strengthening healthcare networks; (c) support the 35 Supported first by the WB Plan Nacer I (US$135 million) and Plan Nacer II (US$300 million), Provincial Public Health Insurance Development Project, The Sumar I Program (P106735 – US$600 million) –all already closed– and then Effective UHC Project (P163345 – US$550 million) now under implementation, supporting the Sumar II Program, closing on December 31, 2023. 36 Including: (i) the Protecting Vulnerable People against NCDs or “Proteger� Project (US$350 million – P133193), supported by the WB, closing on November 30, 2022, and (ii) other national programs such as Redes and REMEDIAR. Apr 03, 2023 Page 14 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) integration and coordination between the public, private, and social security subsectors, through the progressive harmonization of the health services packages; (d) promote a comprehensive, efficient, and equitable management strategy for drugs and health technologies. In addition, advancing the agenda already started on climate change response, mitigation, and adaptation sectoral strategy. 26. The Plan is designed along five areas: (a) Equitable access to healthcare; (b) Quality of healthcare; (c) Efficiency; (d) Integration and health services networks; and (e) Health intelligence. Furthermore, the Plan’s activities are structured around eleven strategic lines (Figure 2) Figure 2. NIHP Areas and Strategic Lines Notes: Grey highlighted boxes illustrate the boundaries of the Program supported by the PforR. 27. The MSN has assigned an initial budget for each of the 11 strategic lines of the NIHP, which include 14 programs and 29 budget activities. The NIHP has a projected budget of US$920 million for 2023, which represents approximately 51 percent of the central administration budget of the MSN (US$1,791 million, without decentralized agencies). For the period 2023-2025, the NIHP has an estimated total budget of US$3,072 million. 28. The proposed PforR will support investments and activities aimed at increasing equitable and effective coverage to health services offered by public health facilities for selected lines of care, through improved quality and integration of care in the public subsector; and obtaining efficiency improvements through coordination and integration of health subsystems and climate change actions. To this end, the beneficiary population of the PforR is mainly constituted by the population without formal health insurance that exclusively relies on the country’s public subsystem (19.9 million people as of January 2023).37 However, the entire country population of 45,8 million38 people will benefit from activities under RA4 that focus on the further functional integration/coordination of subsectors and the overall system’s efficiency, by harmonizing a package of cost-effective services, promoting efficiencies in the purchasing 37 Population enrolled at Sumar Program and registered in the MOH SISSA. 38 https://data.worldbank.org/country/AR Population, Total: 45,808,747 (2021) Apr 03, 2023 Page 15 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) of essential drugs including digital prescription, promoting adaptation and mitigation measures to climate change, and promoting regulations against NCD’s risk factors. 29. For each of these RAs, the Program proposes activities to improve institutional processes and health service delivery and defines outputs needed to achieve the Program Development Indicators (PDIs) (see Figure 2). To this end, the PforR’s RA1 is a crosscutting area that supports the legal and administrative framework for the foundation of the PforR, in terms of consolidating and institutionalizing results-based health financing mechanisms used by ongoing WB financing projects at the national and provincial levels. To this end, this RA1 will enable the MSN to purchase a package of health services defined under criteria of quality, efficiency, and financial protection to the MSPs, for those without formal health coverage, thereby fully institutionalizing the WB-supported Sumar Program. The additional RAs address the main identified challenges of: (a) inequities in the coverage of quality essential services timely delivered to the eligible population (RA2); (b) an inadequate care model to address the country’s evolving and NCDs-dominated disease burden as well as the challenges to coordination and continuation of care resulting from the fragmentation of the public delivery network (RA3); and (c) the weaknesses in the efficiency use of health resources due to the highly fragmented and decentralized nature of the health system (RA4). 30. Furthermore, RA2 to RA3 have a strong focus on equity as they aim to improve the delivering of relevant care for those vulnerable groups with worse-off health outcomes. To this end, the goal under RA2 is to improve equitable and effective coverage of essential health services including for vaccines and NCD prevention, screening, and care (with an emphasis on breast cancer, mental health, and GBV survivors among others). RA2 also supports capitation payments that include an equity component to benefit those provinces with worse health outcomes. The goal under RA3 is to improve care quality by fostering coordination and continuation of care, particularly coordination among health providers from different levels of care, and different ancillary services such as labs. Through this coordination, RA2 aims to improve effective coverage, particularly of NCD services such as breast cancer treatment. Therefore, RA3 would also support the National digital health system and the interoperability strategy, as a precondition for care coordination. 31. The proposed PforR would support four out of five areas of the Government’s NIHP 2023-2026 over the three-year period of 2023-2025 (Figure 2). As mentioned above, the three NIHP’s objectives are organized around five areas. For each area, NIHP specifies strategic lines and activities. The PforR would support part of the Government Program for the period 2023-2025, considering the activities in each area and strategic line that are linked to the PforR’ s results areas (RA). This sets the boundaries of the PforR, focusing on supporting the following strategic lines; 1) on the institutionalization of the Sumar Program; 2) on gender diversity and GBV; 3) on mental health promotion; 4) on quality of integrated healthcare with evaluation of health facilities; 5) on quality for health promotion and regulations linked to reducing NCDs risk factors; 7) on the strategic purchase of drugs; 9) on the implementation of the integrated health services package (PAISS); and 10) on health information systems. Table A3.5 in Annex 3 shows the scope of the NIHP and the corresponding PforR boundaries. This selection of these specific budget lines was made based on key areas that could support the PforR development objectives in a three-year period; where Bank support is relevant based on the long-term commitment with the related programs in the sector; and where programs have had historically high levels of execution so as to ensure an adequate flow of resources. Apr 03, 2023 Page 16 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 32. Results area 1: Consolidated and institutionalized health financing mechanisms. The activities under RA1 establish mechanisms and processes that set the basis for the results to be achieved under the other results areas. This RA would support the strengthening of the MSN and MSPs in their health service purchasing function, through the consolidation of financial transfer mechanisms to the MSPs and the refinement of payment modalities for purchasing cost-effective health care services to the participating health care provides delivered to the eligible population (including results-based schemes). To this end, RA1 is designed to be a foundational area that would allow the implementation of follow up interventions and results under RA2 and RA3. DLRs under RA1 related with the approval of norms, regulations, and framework agreements are needed for the implementation of Program. In addition, RA1 institutionalizes the Sumar and Proteger programs and provides continuity to the mechanisms the Program supported. RA1 provides the basis for RA2, which includes a Disbursement-Linked Indicator (DLI) related to the population that receives effective basic health coverage in the public subsector, and RA3, which includes a PDO indicator on the timely treatment of breast cancer. Both indicators have been measured by the Sumar Program (see Box 2, above). Box 2. Effective Coverage under the NIHP’s Program; an actionable metric for tracking progress towards achieving UHC. Effective coverage is linked to three dimensions of the provision of services: need, use, and quality. The indicator refers to timely access and utilization with quality standards of health services. Thus, the indicator is not just simply considering if the person is insured under any type of health coverage (public subsystem, private, social security institutions) which is mainly summarized by measuring the enrollment status in the insurance schemes. Effective coverage goes also beyond the enrollment and crude coverage39, to capture the effective contact of a person with the health system in terms of having consumed the needed health services according to certain clinical protocols and quality guidelines. PAHO-WHO defines “effective service coverage� as the “proportion of people in need of services who receive services of sufficient quality to obtain potential health gains� 40. To this end, it describes the extent of effort with which a health system ensures the provision of health services with standardized quality and according to the population’s needs and health conditions. Moreover, effective coverage considers different facto rs, connecting demand for healthcare services and access, with utilization and quality in the provision of those services41. Indicators’ measurement and international evidence While crude coverage shows the people who use an intervention there is no linkage between the use of the intervention and the related quality that would bring to health gains. To this end, whether the value 100 percent in crude coverage shows that all the people that needed given intervention uses it, it has been found that increases and improvements in availability, access, and use of health services, especially among poor populations, do not always translate into the improvements in health gains. To get effective coverage, the indicator’s ratio should be adjusted to quality or health gain value, which is between 0 and 1; where 0 is no h ealth gain and 1 is the maximum gain possible for that intervention.42 Origin of the Indicator in Argentina The indicator was introduced in Argentina back 2012, when the Sumar Program expanded its scope to expand population groups (before was only for maternal and child population) and health services. Then, the coverage indicator was redefined to measure the contribution to the project in increasing utilization and quality of key health services for the uninsured target population. Then, Sumar Program introduced a new PDI; “Proportion of eligible population with effective coverage� 43. To be considered a “Sumar 39 Crude coverage simply takes the fraction of those who use an intervention into account without the quality component (gain in health) while the effective coverage adjusts this concept for the quality or effectiveness of the intervention 40 PAHO. (2021). Assessing barriers to effective coverage with health services. PAHO/AMRO webinar series on essential public health functions. 41Shengelia, Tandon, Adams and Murray. (2005). Access, utilization, quality, and effective coverage: An integrated conceptual framework and measurement strategy. Social Science & Medicine, Volume 61, Issue 1. 42 Ali Jannati,1, Vahideh Sadeghi, Ali Imani, and Mohammad Saadati (2018) Effective coverage as a new approach to health system performance assessment: a scoping review. BMC Health Serv Res.2018; 18: 886. 43 Baseline effective coverage rate for children and women up to 64 years was only 7% in 2012. Apr 03, 2023 Page 17 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) beneficiary�, in addition to be enrolled in the program, the person must receive a health service (according to each defined age group and quality standards) in a certain period of time. Those health services have been selected for their relevance for each population group, considering the critical health conditions and burden of disease, and have clinical guidelines for checking timely utilization and quality standards. The list of health interventions is extensive and includes general health check-up, prenatal check- up, immunizations, ophthalmological check-up, dental check-up, gynecological check-up, mammography, PAP, among others. In addition, the capitation payments under the Sumar Program were based on the number of enrolled beneficiaries with effective coverage. Indicator’s trajectory in the Country During almost 10 years, Sumar CEB indicator has been central to monitoring the contribution of the Program to improving the access and utilization of quality health services in Argentina and is a core indicator for the MSN authorities to assess the improvements in access, equity, and quality of services in the public health subsector. 33. Results area 2: Increased equitable and effective coverage to public health services for the eligible population. This RA would seek to increase equitable and effective coverage of key health services (defined under RA1) delivered with quality standards in a timely manner. The aim is recovering the losses resulting from the COVID-19 pandemic and increased effective coverage for the population under the public sector. This RA would close gaps with a special focus on prevention and control of chronic conditions, such as breast cancer, pulmonary disease; improving screening and control of mental health; GBV survivors related services; and high complexity services for children, such as pediatric cancer. In addition, this RA would also support the Government’s strong focus on reducing gender gaps in service delivery. Efforts towards supporting the assignment of beneficiaries to a regular primary care provider (“empanelment�) under Sumar Program will continue, which is expected to have a strong positive impact on the utilization of key preventive health services by men, whose utilization levels are currently much lower than among women. In turn, this would increase NCD screening among men, and would help reduce the gender gap for the NCD burden of disease. The Program includes several indicators to be monitored on a gender-disaggregated basis, or that will track utilization among women only. RA2 relates to area 1 (equitable coverage) of the Government’s program. 34. Results area 3: Improved quality and integration of care in the public subsector. This RA would support the Government in implementing measures aimed at improving quality and integration of health services, coordination of care and continuation of care. It is related to area 2 (quality) and area 4 (integration). Activities included under this RA are the evaluation of healthcare facilities according to quality standards designed by the MSN, focusing on increasing the number of providers adhering to quality protocols and guidelines that include environmental and social standards; actions to strengthen health workforce, including institutionalizing competency-based training around mental health; actions to georeferencing of orientation teams to recognize, manage, and refer GBV survivors to the appropriate services; actions to strengthen the timely treatment of those women diagnosed with breast cancer and the adoption and implementation of an integrated pediatric cancer network, and the development and implementation of standards for sharing clinical information between health providers across jurisdictions as a precondition for quality and continuation and coordination of care. RA3 would also manage the citizen claims and complaints. 35. Results area 4: Improved efficiency through the coordination and integration of health subsystems. This RA, related to area 3 (efficiency) and area 4 (integration) of the Government’s program, would support coordination between different health subsystems to enhance efficiency. To this end, the PforR is setting the basis of a policy for the much-needed coordination and integration of health services Apr 03, 2023 Page 18 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) across different subsystems. Among other activities, it would include actions to: (a) design and implement an integrated benefit package with protocols and standards of care, advancing the PAISS strategy for the health system overall; (b) improve the efficiency of pharmaceutical inventory through digitalization; and (c) support capacity development for the centralized purchasing of essential medicines, producing savings in its purchase against the retail price. Furthermore, this results area will focus on the regulatory framework necessary to implement climate change adaptation and mitigation strategies. The regulations set in this regard are considered the first steps in the path of promoting an efficient and timely response of the health system facing extreme weather events, air pollution and other climate change phenomena, as well as to reduce its Greenhouse gases (GHG) emissions and carbon footprint (for example, promotion of the green hospital strategy at the provincial level). In that sense, the creation of a National Strategy for Health & Climate Change, and the related adaptation plans, would create the necessary conditions for the future implementation of more cost-effective interventions in terms of linking financing with climate vulnerabilities. Finally, this RA would promote regulatory actions at the MSN and MSPs for the protection of the population against NCD risk factors, such as the implementation of the labeling law, with the goal of preventing NCD-related illness. Table 3. Boundaries of the PforR vs. the Government’s program Government’s program Program supported by the Reasons for non-alignment PforR Program Objective Contribute to the Support improvements in the The PforR will support a set of development of an effective and equitable activities related to the integrated, equitable and coverage of public health institutionalization of mechanisms sustainable health services, and the efficiency of already implemented by the Sumar system that guarantees the health system through and Proteger Programs, and three effective coverage for a better coordination and MSN initiatives: PAISS, the National comprehensive package integration. Strategy for Quality, and Remediar of quality health services. Program for purchasing of essential medicines44. Duration 2023-2025 2023-2025 Geographic The entire country The entire country coverage Results Areas 1 to 5 Areas 1 to 4 The selection has been made based areas on the areas that are key and could achieve results in a three-year period, towards reaching the PforR development goals, and where Bank support is relevant based on the long- term commitment with the related programs in the sector. Overall US$3,072million US$1,713 million, US$300 The MSN has prioritized 10 Financing million of which would be budget programs and 14 activities financed by the WB. under the PforR amounting to US$1,713 million. 44Remediar National Program: MSN’s program for purchasing essential drugs according to an approved methodology (Presidential Decree N° 2724/2002, MSN Resolution N° 248/2020, MSN Resolution N° 1048/2021) Apr 03, 2023 Page 19 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 36. Building on the successful engagement in the health sector in Argentina over the last decade, the WB and the Inter-American Development Bank (IDB) will provide separate financing for the NIHP over the period 2023-2025 to support the Government’s ambitious program. The IDB financing is not a parallel financing but rather a separate financing for which the Government would seek to ensure complementarity between the WB and the IDB loans; to this end, financing instruments agreed upon by the MSN would focus on achieving complementary results towards the sector’s common goals whilst identifying different budget programs to be prioritized by each development partner. Specifically, the IDB will support the Government through the continued financing of the Redes Program.45 This coordinated arrangement has worked successfully in the past, as the IDB-financed operations focused on supporting the developing of care networks and pharmaceutical procurement. To this end, there will be no co- financing of the Program financed by the Bank. In addition, if any activity under the Government’s program receives financing from another development partner, its related contract will be excluded from the expenditure framework for this proposed Program. 37. Furthermore, the PforR builds on the WB’s analytical engagement with the MSN on issues related to quality of care, as well as the integration and efficiency of the health sector. This work includes technical assistance to institutionalize the Sumar Program while further strengthening its design financed by the Primary Health Care Performance Initiative (PHCPI). The PHCPI is a partnership by the WB, the Bill and Melinda Gates Foundation, and the World Health Organization (WHO) that focuses on (a) evaluating the effectiveness of different payment modalities for healthcare services from provinces to public care providers with funds from the Sumar Program, and (b) recommending possible adjustments and refinements to these payment modalities and the monitoring and evaluation arrangements to be implemented under the Program. This engagement also included technical assistance provided to the MSN, MSPs, and the INC on the formalization of a high-complexity/high-cost network; assistance that was focused on an assessment of the current functioning of the pediatric cancer network and the development of a roadmap for its strengthening and formalization. Finally, the engagement also included the implementation of a health system’s strengthening training program provided to high level officials of the MSN and MSPs; training that was focused on the integration of the Argentine health system. Table 4. Program Financing Source Amount (USD Million) % Of Total International Bank for Reconstruction and 300.00 17.50 Development (IBRD) Government Budget 1,413 82.50 Total Program Financing 1,713.00 100.00 45Redes Project (Programa Multifase de Atención Primaria de la Salud para el Manejo de Enfermedades Crónicas No Transmisibles, BID 3772/OC�AR): MSN’s Project for consolidating selected NCD’s health care networks through the integration and coordination of health facilities and teams in all country provinces. Apr 03, 2023 Page 20 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) C. Proposed Program Development Objective(s) Program Development Objective(s) 38. The Development Objectives of the Program (PDO) are to support improvements in: (a) the equitable and effective coverage of public health services, and (b) the efficiency of the health system. The higher objective of the Program is to support UHC through the development of an integrated health system. 39. The proposed PDO indicators are directly associated with the Program’s development objectives: (a) For equitable and effective coverage: Percentage of eligible population with effective health coverage.46 (b) For equitable and effective coverage (quality and integration of care): Percentage of women aged 30-74 with diagnosed breast cancer that receives timely treatment (as registered at individual level). (c) For efficiency: Savings in the purchase of essential medicines relative to the retail price at the time of the award. D. Environmental and Social Effects 40. The WB carried out an Environment and Social Systems Assessment (ESSA) as per the WB Policy – PforR Financing (OPS 5.04-POL 107), that is currently in a draft version for consultations. The draft ESSA provides a comprehensive review of relevant government systems and procedures that address environmental and social issues associated with the Program. The ESSA describes the extent to which the applicable government environmental and social policies, legislation, program procedures and institutional systems are consistent with the core principles of OPS 5.04-POL 107. Finally, the ESSA includes recommendations and Program Action Plans to address the gaps and to enhance performance during Program implementation. Based on the definition of PforR boundaries, the proposed PforR will support four out of five areas of the Government’s NIHP 2023-2027 over the three-year period of 2023 - 2025 as defined under the PforR Program Boundary above. The Program is not expected to contain activities that should be excluded from PforR as established in the WB Policy. 41. For the ESSA, the WB team reviewed the environmental and social systems that are relevant to the Program. The ESSA concluded that the overall risk is Moderate (Moderate Environmental and Moderate Social). The environmental risks of the Program are linked to the management of health care waste (HCW) and waste of electrical and electronic equipment (WEEE), and to climate change and geophysical risks. The main social risks are associated with the possible exclusion of vulnerable groups, including indigenous peoples, from participating in the benefits of the Program. The WB team also 46 Effective health coverage for this indicator is defined as having the eligible population enrolled in the program (currently the Sumar Program) and utilizing one or more essential health services provided according to established quality protocols – from a list of predefined key services listed in the Sumar Program’s Benefit plan. Apr 03, 2023 Page 21 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) addressed the coordination of public policies with the spatial distribution of the population in the territory associated with natural environments and the capacity of the health establishments that implement the accompaniment route to prepare, face and adapt to the impacts of natural disasters, economic crises, pandemics, and climate change. The ESSA found gender gaps, as well as gaps of access to health services by vulnerable groups (for example, people with disability, LGTBI+, ethnic groups, including indigenous peoples, and migrants) and included actions to address these gaps by strengthening the MSN stewardship role in promoting and monitoring intercultural health and vulnerable groups programs at the provincial level. On Citizen Engagement, the ESSA included actions to enhance existing participation and grievance redress mechanisms through the development of a citizen engagement strategy for the public health sector in its different levels. Environmental gaps in the management of HCW and WEEE were also identified, which are addressed with Program Action Plan actions and recommendations. Virtual and in person consultations are being conducted with key health stakeholders and representatives of vulnerable groups as part of the preparation of the ESSA. The Draft ESSA has been available on the Government of Argentina website for public consultation since March 30 and will be subsequently reviewed to include comments into the final version. The definitive version of the ESSA will be disclosed on the WB’s website after it is published in the MSN website. E. Financing Table 5. Program Financing Sources Amount % of Total (USD Million) Counterpart Funding 1,413.47 82.49 Borrower/Recipient 1,413.47 82.49 International Bank for Reconstruction and Development 300.00 17.51 (IBRD) Total Program Financing 1713.47 . CONTACT POINT World Bank Name : Vanina Camporeale Designation : Senior Operations Officer Role : Team Leader(ADM Responsible) Telephone No : 5260+3675 / Email : vcamporeale@worldbank.org Name : Maria Eugenia Bonilla-Chacin Designation : Program Leader Role : Team Leader Apr 03, 2023 Page 22 of 23 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Telephone No : 5260+3626 / Email : mbonillachacin@worldbank.org Name : Marvin Ploetz Designation : Senior Economist Role : Team Leader Telephone No : 202-458-1705 Email : mploetz@worldbank.org Borrower/Client/Recipient Borrower : Argentine Republic Contact : Title : Telephone No : Email : Implementing Agencies Implementing National Ministry of Health Agency : Secretary of Administrative Contact : Mr. Mauricio Monsalvo Title : Management Telephone No : 541150161300 Email : mmonsalvo@msal.gov.ar FOR MORE INFORMATION CONTACT The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 473-1000 Web: http://www.worldbank.org/projects Apr 03, 2023 Page 23 of 23