FOR OFFICIAL USE ONLY Report No: PAD5270 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT PROGRAM APPRAISAL DOCUMENT ON A PROPOSED LOAN IN THE AMOUNT OF US$300 MILLION TO THE ARGENTINE REPUBLIC FOR A PROGRAM FOR EFFECTIVE UNIVERSAL HEALTH COVERAGE AND NATIONAL HEALTH SYSTEM INTEGRATION June 2, 2023 Health, Nutrition & Population Global Practice Latin America And Caribbean Region 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 May 8, 2023) Currency Unit = Argentine Peso ARS 226.22 = US$1 FISCAL YEAR January 1 - December 31 Regional Vice President: Carlos Felipe Jaramillo Regional Director: Luis Benveniste Country Director: Marianne Fay Practice Manager: Michele Gragnolati Task Team Leader(s): Vanina Camporeale, Maria Eugenia Bonilla-Chacin, Marvin Ploetz The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) ABBREVIATIONS AND ACRONYMS COVID-19 2019 Coronavirus disease DGPFE General Directorate of Projects with External Financing (Dirección General de Proyectos con Financiamiento Externo) DLI Disbursement-linked Indicator DLR Disbursement-linked Result DNFSP National Directorate of Provincial Systems Strengthening (Dirección Nacional de Fortalecimiento de los Sistemas Provinciales) e-SIDIF Integrated Financial Information System Internet (Sistema Integrado de Información Financiera Internet) ESSA Environment and Social Systems Assessment GBV Gender-based Violence GDP Gross domestic product HMIS Health Management and Information System IDB Inter-American Development Bank IMF International Monetary Fund INC National Cancer Institute (Instituto Nacional del Cáncer) IRI Intermediate Results Indicator IRR Internal Rate of Return MMR Measles, Mumps, and Rubella MSN National Ministry of Health (Ministerio de Salud de la Nación) MSP Provincial Ministries of Health (Ministerios de Salud Provinciales) NCD Noncommunicable diseases NIHP National Integrated Health Plan NOMIVAC Federal Vaccination Registry (Registro Federal de Vacunación) PAISS Argentine Integrated Health Services Plan (Plan Argentino Integral en Servicios de Salud) PDI Program Development Indicator PDO Program Development Objective PforR Program for Results POM Program Operations Manual RA Results Area RITA Argentina Institutional Tumor Registry (Registro Institucional de Tumores de Argentina) SES Secretariat of Equity in Health (Secretaría de Equidad en Salud) SGA Secretariat of Administrative Management (Secretaría de Gestión Administrativa) The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) SIGEN National Internal Audit Agency (Sindicatura General de la Nación) SISA Health Integrated Information System (Sistema Integrado de Información Sanitaria Argentino) SITAM Screening Information System (Sistema de Información para el Tamizaje) UNDP United Nations Development Programme WHO World Health Organization YLL Year of Life Lost The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) TABLE OF CONTENTS DATASHEET .......................................................................................................................................... 1 I. STRATEGIC CONTEXT .................................................................................................................... 7 A. Country Context ....................................................................................................................... 7 B. Sectoral and Institutional Context ............................................................................................ 8 C. Relationship to the CPS/CPF and Rationale for Use of Instrument .......................................... 17 II. PROGRAM DESCRIPTION ............................................................................................................ 18 A. Government Program ............................................................................................................ 18 B. Theory of Change ................................................................................................................... 19 C. PforR Program Scope .............................................................................................................. 23 D. Program Development Objective(s) (PDO) and PDO Level Results Indicators .......................... 27 E. Disbursement Linked Indicators and Verification Protocols .................................................... 27 III. PROGRAM IMPLEMENTATION .................................................................................................... 35 A. Institutional and Implementation Arrangements.................................................................... 35 B. Results Monitoring and Evaluation ......................................................................................... 36 C. Disbursement Arrangements .................................................................................................. 37 D. Capacity Building ................................................................................................................... 38 IV. ASSESSMENT SUMMARY ............................................................................................................ 39 A. Technical (including program economic evaluation) ............................................................... 39 B. Fiduciary ................................................................................................................................ 41 C. Environmental and Social ....................................................................................................... 43 D. Gender ................................................................................................................................... 44 E. Climate Change ...................................................................................................................... 47 V. RISKS .......................................................................................................................................... 48 ANNEX 1. RESULTS FRAMEWORK MATRIX.......................................................................................... 51 ANNEX 2. DISBURSEMENT LINKED INDICATORS, ARRANGEMENTS AND VERIFICATION PROTOCOLS .. 65 ANNEX 3. TECHNICAL ASSESSMENT .................................................................................................... 87 ANNEX 4. FIDUCIARY SYSTEMS ASSESSMENT ................................................................................... 115 ANNEX 5. SUMMARY ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT .................................. 134 ANNEX 6. PROGRAM ACTION PLAN .................................................................................................. 138 ANNEX 7. IMPLEMENTATION SUPPORT PLAN .................................................................................. 142 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DATASHEET BASIC INFORMATION BASIC_INFO_TABLE Country(ies) Project Name Argentina Program for Effective Universal Health Coverage and National Health System Integration Project ID Financing Instrument Does this operation have an IPF component? Program-for-Results P179595 No Financing Financing & Implementation Modalities [ ] Multiphase Programmatic Approach (MPA) [ ] Fragile State(s) [ ] Contingent Emergency Response Component (CERC) [ ] Fragile within a non-fragile Country [ ] Small State(s) [ ] Conflict [ ] Alternate Procurement Arrangements (APA) [ ] Responding to Natural or Man-made Disaster [ ] Hands-on Enhanced Implementation Support (HEIS) Expected Project Approval Date Expected Closing Date 29-Jun-2023 31-Dec-2026 Bank/IFC Collaboration No Proposed Program Development Objective(s) To support improvements in: (a) the equitable and effective coverage of public health services, and (b) the efficiency of the health system. Organizations Borrower : Argentine Republic Implementing Agency : National Ministry of Health Contact: Mr. Mauricio Monsalvo Page 1 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Title: Secretary of Administrative Management Telephone No: 541150161300 Email: mmonsalvo@msal.gov.ar COST & FINANCING FIN_SUMM_WITH_IPF SUMMARY Government program Cost 3,072.00 Total Operation Cost 1,713.00 Total Program Cost 1,713.00 Total Financing 1,713.00 Financing Gap 0.00 Financing (USD Millions) Counterpart Funding 1,413.00 Borrower/Recipient 1,413.00 International Bank for Reconstruction and Development (IBRD) 300.00 Expected Disbursements (USD Millions) Fiscal 2023 2024 2025 2026 2027 Year Absol 0.00 140.00 39.00 100.00 21.00 ute Cumul 0.00 140.00 179.00 279.00 300.00 ative INSTITUTIONAL DATA INSTITUTIONAL DATA TBL Practice Area (Lead) Contributing Practice Areas Health, Nutrition & Population Page 2 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Climate Change and Disaster Screening This operation has been screened for short and long-term climate change and disaster risks SYSTEMATIC OPERATIONS RISK-RATING TOOL (SORT) Risk Category Rating 1. Political and Governance ⚫ Substantial 2. Macroeconomic ⚫ Substantial 3. Sector Strategies and Policies ⚫ Substantial 4. Technical Design of Project or Program ⚫ Moderate 5. Institutional Capacity for Implementation and Sustainability ⚫ Substantial 6. Fiduciary ⚫ Substantial 7. Environment and Social ⚫ Moderate 8. Stakeholders ⚫ Low 9. Other 10. Overall ⚫ Substantial COMPLIANCE Policy Does the program depart from the CPF in content or in other significant respects? [ ] Yes [✔] No Does the program require any waivers of Bank policies? [ ] Yes [✔] No Legal Operational Policies Triggered Projects on International Waterways OP/BP 7.50 No Projects in Disputed Areas OP/BP 7.60 No Legal Covenants Page 3 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Sections and Description Schedule 2, Section I.A (Program Institutions). The Borrower, through MSN, shall be responsible for the overall implementation and oversight of the Program. To this end, the Borrower, through MSN, shall maintain within SES, throughout Program implementation, a technical and operational coordination team with a structure, functions, and responsibilities acceptable to the Bank, as set forth in the POM, including, inter alia: (a) the DNFSP, which shall be responsible for coordinating the Program activities through MSN’s different secretariats, directorates, and centers, including monitoring compliance with the data to be reported for the DLIs/DLRs; and (b) the SGA, which shall be responsible for the Program’s budget management, procurement, and financial management activities. Sections and Description Schedule 2, Section I.B. (Participation Agreements) 1. Prior to carrying out activities with a Participating Province under the Program, the Borrower, through MSN, shall enter into an agreement with each of the Participating Provinces (“Participation Agreement”), which shall include, inter alia, the Participating Province’s obligations to carry out the National Integrated Health Plan in accordance with its guidelines and instructions, which shall include the obligations related to the Program, including, inter alia, the ones set forth in the POM, the PAP, and the Anti-corruption Guidelines. 2. The Borrower, through the MSN, shall cause each Participating Province to exercise its rights under each Participation Agreement in such manner as to protect the interests of the Borrower and the Bank and to accomplish the purposes of the Loan. Except as the Bank shall otherwise agree, the Borrower, through the MSN, shall not assign, amend, abrogate, or waive the abovementioned obligations related to the Program. Sections and Description Schedule 2, Section I.C (Program Operational Manual) 1. The Borrower, through MSN, shall carry out the Program in accordance with the provisions set forth in the Program Operational Manual (“POM”), which shall include, inter alia: (a) the Program Action Plan; (b) the fiduciary, environmental, and social systems for the Program; (c) the DLIs/DLRs, the Verification Protocol for the DLIs/DLRs, and the results monitoring framework; and (d) the functions, responsibilities, and composition of implementation teams within MSN, in charge of Program implementation, including their obligation to comply with the ESCP and the Anti-Corruption Guidelines. 2. Except as the Bank may otherwise agree in writing, the Borrower, through MSN, shall not abrogate, amend, suspend, waive, or otherwise fail to enforce the POM or any provision thereof. In case of any conflict between the terms of the POM and this Agreement, the provisions of this Agreement shall prevail. Sections and Description Page 4 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Schedule 2, Section I.D (Verification Arrangements) 1. The Borrower, through MSN, shall appoint and maintain, throughout Program implementation, a verification agent for the Program acceptable to the Bank, in accordance with the terms of reference acceptable to the Bank. 2. The Borrower, through MSN, shall ensure that the verification agent referred to in the preceding paragraph shall: (a) verify the data and other evidence supporting the achievement(s) of one or more DLRs and recommend corresponding payments to be made in accordance with the Verification Protocol; and (b) submit to MSN the corresponding verification reports in a timely manner and in form and substance satisfactory to the Bank. Sections and Description Schedule 2, Section I.E (Program Action Plan) 1. The Borrower, through MSN, shall: (a) undertake the actions set forth in the Program Action Plan in a manner satisfactory to the Bank; (b) except as the Bank and the Borrower, through MSN, shall otherwise agree in writing not to assign, amend, abrogate, or waive, or permit to be assigned, amended, abrogated, or waived, the Program Action Plan, or any provision thereof; and (c) maintain policies and procedures adequate to enable it to monitor and evaluate, in accordance with guidelines acceptable to the Bank, the implementation of the Program Action Plan. Sections and Description Schedule 2, Section IV.B (Withdrawal Conditions) 1. No withdrawal shall be made: (a) on the basis of DLRs achieved prior to the Signature Date, except that withdrawals up to an aggregate amount not to exceed USD 50,000,000 may be made on the basis of DLRs achieved prior to this date but on or after October 31, 2022; and (b) for any DLR under Categories (1) to (9) until and unless the Borrower, through MSN, has furnished evidence satisfactory to the Bank that said DLR has been achieved. 2. Notwithstanding the provisions of Part B.1(b) of this Section, the Borrower, through MSN, may withdraw: (i) an amount not to exceed USD 40,000,000 as an advance, provided, however, that if the DLRs in the opinion of the Bank, are not achieved (or only partially achieved) by the Closing Date, the Borrower, through MSN, shall refund such advance (or portion of such advance as determined by the Bank in accordance with the scalability formulas (i.e., proportional amount) set forth in Schedule 4 of this Agreement, when applicable) to the Bank promptly upon notice thereof by the Bank. Except as otherwise agreed with the Borrower, the Bank shall cancel the amount so refunded. Any further withdrawals requested as an advance under any Category shall be permitted only on such terms and conditions as the Bank shall specify by notice to the Borrower. 3. Notwithstanding the provisions of Part B.1 (b) of this Section, if any of the DLRs under Categories (1) through (9) has not been achieved by the date by which the said DLR is set to be achieved (or such later date as Page 5 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) the Bank has established by notice to the Borrower, through MSN, the Bank may, by notice to the Borrower: (a) except for Non-Scalable DLRs, authorize the withdrawal of such amount of the unwithdrawn proceeds of the Loan then allocated to said Category which, in the opinion of the Bank, corresponds to the extent of achievement of said DLR (Scalable DLRs), such amount to be calculated in accordance with the formula (i.e., proportional amount) set out in the Schedule 4 of this Agreement; (b) only for Non-Scalable DLRs, withhold the allocated for the unmet DLR(s) and, at its sole discretion, may authorize, at a later date, the full release of the amounts so withheld, if and when the Bank is satisfied that the respective DLR(s) has/have been achieved; (c) reallocate all or a portion of the proceeds of the Loan allocated to any DLR to any other DLR within the same DLI; and/or (d) cancel all or a portion of the proceeds of the Loan then allocated to said DLR. Conditions Type Financing source Description Effectiveness IBRD/IDA Section 4.01. The Additional Condition of Effectiveness consists of the following: the Borrower, through MSN, has adopted the Project Operational Manual in form and substance acceptable to the Bank. Page 6 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) I. STRATEGIC CONTEXT A. 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. Argentina is a federal state; 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.2 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 program for 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 Standby Agreement (US$40.5 billion) and provided 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. On April 1, 2023, the Executive Board of the IMF completed the fourth review of Argentina’s Extended Fund Facility, allowing for an immediate disbursement of about US$5.4bn in early April 2023. 5. Despite meeting all the performance criteria under the IMF Extended Fund Facility by end-2022, Argentina’s macro-fiscal situation remains challenging. According to the IMF statement, prudent macroeconomic 1 https://www.censo.gob.ar 2 Note that these numbers correspond to the Argentine national poverty rate. The “Indigence Line” or national severe poverty line is a threshold that establishes whether households have sufficient income to cover the Basic Food Basket. Households that do not exceed the indigence line are considered indigent. The “Poverty Line” extends the threshold to also include other basic non-food consumption. In both cases, household incomes are those collected by the Permanent Household Survey (EPH). Using the upper middle-income poverty rate threshold of US$6.85 per day, in 2021 14 percent of the population was living in poverty (World Bank. Macro Poverty Outlook, 2022). Page 7 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 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 (104 percent year-over-year, as of March 2023), denting purchasing power. A severe drought is strongly affecting agricultural production in 2023, reducing exports and fiscal revenues while limiting the capacity of the Central Bank to accumulate international reserves. While the fiscal target for end-2022 has been met, the impact of the drought on fiscal revenue, among other factors, has caused the government to miss the original target by the end of March 2023. 6. In this context, the Government is increasing efforts towards a gradual macroeconomic stabilization program that contains a broad set of economic policies. 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 improve 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.3 According to World Bank’s (WB) estimations, 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.4 From 2000 to 2011, flooding events affected 5.5 million people. The country is also vulnerable to wildfires, storms, landslides, droughts, and extreme temperatures. 5 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 change.6 B. Sectoral and Institutional Context 8. Argentina’s aggregated health outcomes have improved significantly in the past decades, but considerable intranational inequalities persist. Improvements in health outcomes are the result of increased 3 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 4 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. https://openknowledge.worldbank.org/handle/10986/31805. 5 Emergency Events Database, https://www.emdat.be/ 6 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 Page 8 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) access to essential health services, especially maternal and child services and, to a more limited extent, services for noncommunicable diseases (NCD). 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 in 2015 to 77 years in 2019, until the COVID-19 pandemic erased previous gains and life expectancy fell to 76 in 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 relatively higher. Also, the overall adjusted mortality rate is higher in the northern provinces. 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 9. Despite the improvements, health indicators are still worse than in countries with similar income and levels of health spending. Comparable countries such as Costa Rica and Chile fare better in terms of key health outcomes, including indicators of health system effectiveness, such as infant mortality rate and age-standardized mortality rate related to NCD (Table 1). 7 Data source: National Risk Factor Surveys from 2005 and 2018 (the latest available edition). 8 Source: World Bank World Development Indicators. Page 9 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Table 1. Health Outcomes and Expenditure in Argentina and Comparator Countries (2018) Argentina Chile Colombia Costa Rica Uruguay Immunization, DPT vaccine (percentage of children ages 86 95 92 94 91 12-23 months) Mortality from cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases between exact ages 30 and 16 10 10 10 17 70 (percentage) Infant Mortality Rate (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 (PPP) 23,306 24,740 14,866 20,994 23,588 (current international $) Current Health Expenditure as GDP percentage 10 9 8 8 9 Current Health Expenditure per Capita in Purchasing 1,990 2,306 1,155 1,337 2,169 Power Parity (PPP) Source: World Bank World Development Indicators and World Health Organization Global Health Expenditure Database, as of May 01, 2023. 10. 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 services from private providers that fluctuate considerably depending on the economic situation.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. The poor10 are likely to have the lowest coverage of essential health services and less likely to receive essential health services such as NCD screening and treatment (Table 2). Table 2. Differences in Service Provision across Subsystems (2018) Screening/Preventive Test Private/Social Only Public Health Insurance Coverage Colon cancer screening in the last two years 35.2% 16.8% A mammography in last two years 70.7% 46.4% A PAP smear 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: The different tests/screenings presented in Table 2 apply to and are calculated for different age and gender groups in accordance with the corresponding clinical guidelines. For instance, women aged 50 to 70 years are the relevant reference group for mammographies. 9Source: Permanent Household Survey. Second quarter 2022. National Institute of Statistics and Censuses (INDEC). 10Around 40 percent of the total population relies exclusively on the public sector, including almost 60 percent of the poor and about 75 percent of the extremely poor (according to the 2022 Permanent Household Survey). Page 10 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 11. The effects of the COVID-19 pandemic and the economic recession exacerbated the pressure to provide access to public health services, as services were disrupted by lockdowns and social distancing, while the uninsured population grew. As of December 2022, about 43 of the population rely exclusively on the public system, compared to 36 percent in December 2019.11 At the same time, the COVID-19 pandemic, lockdowns and social distancing 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 2020.12 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 percent vs. 71.7 percent).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,15 highlighting an urgent need for the public delivery network to provide quality mental health services. 12. 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 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. 13. Improving health outcomes requires more equitable coverage and better quality of the public health services. Effective health coverage refers to the coverage that provides timely access to services with 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- 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). 16 The Ministry of Women, Gender, and Diversity, 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 the DEIS from the National Ministry of Health (MSN), 5,820 women died from breast cancer in 2021. Breast Page 11 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 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 coverage.21 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. The 5-year survival rate in Argentina is much lower (67.6 percent) compared to high-income countries (more than 80 percent).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 provision of quality care for these conditions requires continuity of care, both across time and across levels of providers. 14. 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 healthcare 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 healthcare. This multidimensional fragmentation is not only linked to the non-contributory subsystem with its 24 Provincial Ministries of Health (MSP), 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 NCD. 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 covered by the public system. For instance, referrals and counter-referrals remain mostly informal and based on health personnel relationships with the referral center. This situation not only limits the quality of the services provided, but also causes the duplication or gaps in services provided. For high complexity diseases, such as congenital cardiopathies or pediatric cancers, this fragmentation generates even larger barriers for quality care, since effective services beyond the provincial level are needed. 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. 24 Kurt C. Stange, MD, PhD, Editor. The Problem of Fragmentation and the Need for Integrative Solutions. PMCID: PMC2653966 PMID:19273863 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2653966/ Page 12 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) (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. 15. The National Ministry of Health (MSN) has made significant and successful efforts to improve effective and equitable coverage of health services through flagship programs that received the support of the World Bank and other development partners. The Nacer and Sumar programs (Box 1) have improved effective coverage of essential health services for the population without health insurance. As widely documented, 25 these Bank- financed operations have had innovative design features with substantial achievements in terms of relevance, efficacy, and efficiency in providing quality healthcare services for the uninsured. Particularly noteworthy in the context of the pandemic is the Sumar program that contributed to strengthening Argentina’s public healthcare 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 and the positive results they have achieved. 25 See, among others: (i) Cortes, R (2013) “Argentina - Increasing Utilization of Healthcare 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 Healthcare 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; and (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. Page 13 of 144 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 were supported by a series of Bank-financed Projects[1] over 15 years and laid the foundation for a national policy that seeks to achieve universal health coverage through a public insurance scheme. The cornerstone of this policy is to reduce inequalities in access to services and to increase timely coverage 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 (around 2.5 percent of the provincial health budget) and its benefit package has grown to include almost 700 interventions. The Sumar Program finances capitation payments to the MSPs for general health interventions included in the Health Benefit Plan to improve coverage and quality of health services to the eligible population. Based on results-based incentives for the provinces and service providers, and robust quality-control mechanisms, Sumar helped develop better provincial health insurance systems, expanding their territorial coverage, beneficiary population, health services, delivery strategies, health information systems and registers, and instrumental strategies. The capitation payment is an insurance premium calculated for prioritized general health services selected based on their cost-effectiveness in preventing and treating critical diseases. The capitation payment considers the full cost of the per capita insurance premium, based on the difference between the full cost of the prioritized package of quality health services and the actual public spending on these services. The capitation payment includes an “equity” component that considers the life expectancy at birth in each province as a proxy for health outcomes. These values are reviewed and updated periodically. The maximum value of capitation payment is attained when a province attains a perfect score on a set of carefully selected indicators that track the provincial performance against reaching overall program goals. Sixty percent of the payment is based on eligible people enrolled and with effective coverage and the remaining share is determined according to provincial performance. The Health Benefit Plan also covers services for selected high-complexity diseases by a fund financed through a capitation payment based on the total number of the eligible population enrolled in 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). The now called “National Fund for Equity in Health (FONES)”, also has a high‐complexity perinatal package, that includes congenital malformations, services for acute myocardial infarction, and COVID-19 treatment. The Sumar Program has made remarkable progress in institutionalizing a results-based mechanism in the health sector. A key bottleneck to scaling up and institutionalizing result-based programs is related to public financial management systems and their ability to scale up result-based payments. In the case of the Sumar program, major advances were made in building the capacity of MSN, but additional support is needed. The Proteger Program supported the implementation of a national and provincial NCD strategy to protect vulnerable populations only covered by the public health system and ensure access to quality services, improve healthcare and carry out epidemiological surveillance. Bank-financed support (P133193) specifically contributed to improve the readiness of public health facilities to provide expanded health services and reduce NCD risk factors (i.e., tobacco, physical inactivity, and unhealthy diets). 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 NCD. To this end, the operation supported: (i) the implementation of systematic assessment tools focusing on the delivery of NCD services in primary healthcare facilities with financial incentives provided under a result base mechanism; (ii) the development of provincial plans for an integrated approach toward NCD detection and treatment and underlying risk factors; and (iii) NCD training to health staff at the provincial level. [1] P071025, P095515, P106735, P163345, and P174913 16. In addition, the MSN has been implementing strategies to improve financial protection and access to services. According to the National Household Expenditure Surveys 2004-2005 and 2017-2018, there is a 25 Page 14 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 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 ability to further improve financial protection and access to services. 17. Additional efforts are needed to further improve the equitable and effective coverage of key health services and the overall efficiency of the sector. These include efforts by the MSN to tackle: (i) the remaining inequalities in effective coverage of services; (ii) the lack of an integrated and people-centered delivery network, particularly for the care of patients with NCD and mental health conditions; and (iii) 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 in healthcare services. 18. Climate change is posing additional threats and challenges to the ability of the health system to provide access and continuity of care due to increased risks of floods and frequency of heatwaves and storms.29 Approximately 52 percent of natural disasters in Argentina are floods, accounting for 95 percent of economic losses from natural hazards. These and other extreme climate events that have doubled since the 1960s are expected to further increase in frequency and severity. These events often result in damages to health facilities, often disabling them completely. Climate change also increases health risks such as water or vector-borne diseases, such as dengue, with more frequent outbreaks during the hot and rainy season. Increased temperatures are already yielding an increase in heat-related morbidity and mortality in the country, particularly in Buenos Aires. During the heatwave in the summer of 2012-2013, there were 1,877 excess deaths. More intense droughts and increased temperatures also create more suitable conditions for more frequent and intense wildfires, causing power outages affecting people and the functioning of health services particularly in remote areas. A changing climate also affects the prevalence of NCD, with an increase of 13.7 percent of hypertension cases documented during severe heat waves. Other climate sensitive NCD, such as mental health disorders, are a key priority in the National Determined Contributions and Argentina’s 2019 Climate and Health Country Assessment30. In this context, improved preparedness and surveillance is urgently needed. 19. Climate change exacerbates inequalities, as the risks affect the underserved populations more, including elderly, women, infants, and the more vulnerable and poor population. The factors that affect a population’s vulnerability to climate are like those that affect health services more broadly. Therefore, improving effective universal health coverage reduces the impacts of climate on underserved groups. Notably, heatwaves impact the elderly more. In the summer of 2012-2013, most heath-related deaths happened with people between 60 and 79 years, and the risk increased further for people 80 years and older. Similarly, women are at higher risk 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. 29 Centro de Investigaciones del Mar y la Atmósfera Cambio climático en Argentina; tendencias y proyecciones https://web.archive.org/web/20150830201422/http://www.ambiente.gov.ar/archivos/web/ProyTerceraCNCC/file/Capitulo%202.pdf 30 Centro de Investigaciones del Mar y la Atmósfera Cambio climático en Argentina; tendencias y proyecciones https://web.archive.org/web/20150830201422/http://www.ambiente.gov.ar/archivos/web/ProyTerceraCNCC/file/Capitulo%202.pdf Page 15 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) than men for heat-related mortality (relative risk 1.58 and 1.34 respectively). Finally, the Organization for Economic Cooperation and Development (OECD) highlights that informal settlements with limited access to safe water and sanitation services are more vulnerable to extreme climate events such as floods. 20. Argentina has committed to achieving ambitious emission reduction targets since its first Nationally Determined Contribution back in 2016. The country has continuously updated and upgraded the ambition of its contributions. During the 2021 Leaders’ Summit on Climate, the country announced its new goal of limiting emissions to 349 MtCOeq by 2030. This represents an increase in ambition of roughly 28 percent compared to the 2016 Nationally Determined Contributions.31 Argentina has built a legal and regulatory framework to respond to these ambitious targets, including a law with minimum budget requirements for climate change mitigation and adaptation (Ley de Presupuestos Mínimos de Adaptación y Mitigación al Cambio Climático Global). This allows government organizations to devote additional resources to achieve the Nationally Determined Contributions.32 The government also established an inter-ministerial and interdisciplinary climate change cabinet to lead the preparation of national plans for: climate change response (“Plan Nacional de Respuesta al Cambio Climático”), mitigation (“Plan Nacional de Mitigación”), adaptation (“Plan Nacional de Adaptación”) and specific sectors (“Planes de Acción Nacionales Sectoriales de Cambio Climático”),33 which includes an action plan and program for the health sector (2021).34,35 The implementation of this plan is in progress as needs coordination with other sectors and among provinces, and strong stewardship from the MSN. 21. 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 2023-2028.36 Its objectives are to: (i) increase effective and equitable coverage of prioritized public health services with minimum quality standards; (ii) improve the integration and continuity of care by strengthening health service networks; (iii) support the integration, coordination and harmonization between the public, private, and social security systems (for instance, through the implementation of the recently approved Argentina Integrated Health Services Plan (PAISS); and (iv) promote a more efficient procurement of drugs and health technologies. 22. Building on successful long-term support and results-based financing of the World Bank, the Government requested a Program for Results (PforR) to support the implementation of the NIHP. The use of financial incentives that build on mechanisms implemented by previous operations, will help strengthen the MSN’s stewardship role in the health system. 37 This PforR and other ongoing operations38 will serve as basis for the implementation of the NIHP. The PforR will be the cornerstone for the full institutionalization of the above- 31 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 32Romero, C.Ramos, P., y Harari, M. (2022c). Evaluación de medidas de eficiencia energética en Argentina. https://ojs.econ.uba.ar› DT-IIEP › article. 33 Ibíd. 34 RESOL-2021-555-APN-MS. Programa nacional de reducción de riesgos para la salud Asociados al cambio climático, and RESOL-2021- 2956-APN-MS 35 https://www.argentina.gob.ar/sites/default/files/infoleg/res447-6.pdf 36 Plan Nacional Integrado de Salud 2023-2028. 37 Supported first by the World Bank 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. 38 Including: (i) the Protecting Vulnerable People against NCDs or “Proteger” Project (US$350 million – P133193), supported by the World Bank and closed on November 30, 2022, and (ii) other national programs such as Redes and REMEDIAR. Page 16 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) mentioned programs, as it supports the transition from a program to a national policy that is part of the national strategic health plan. C. Relationship to the CPS/CPF and Rationale for Use of Instrument 23. The Program contributes to the World Bank Group’s twin goals of reducing poverty and promoting shared prosperity and is aligned with its Global Crisis Response Framework, underpinned by the Green, Resilient, and Inclusive Development Agenda. It contributes to the twin goals by improving access and quality of health services for the population not covered by social health insurance; the population more likely to be poor. It also contributes to equity by ensuring the harmonization/coordination of the health system. This Program is also aligned with two of the four pillars of the Global Crisis Response Framework. In line with Pillar 2, Protecting People and Preserving Jobs, it supports the increase in effective coverage of essential health services to the population without health insurance and it also supports the prevention and response to GBV. In line with Pillar 4, Strengthening Policies, Institutions, and Investments for Rebuilding Better, the Program has a strong focus on ensuring the sustainability and institutionalization of previous reforms by strengthening their governance, fiduciary, and financing mechanisms. Similarly, in line with Pillar 4, the Program will support the MSN efforts to strengthen the quality and efficiency of the public health system. 24. The proposed Program is aligned with the World Bank Group FY19-22 Country Partnership Framework 39 (CPF) for the Argentine Republic discussed by the World Bank Executive Directors on April 25, 2019, as revised and extended to FY24 by the Performance and Learning Review40 on May 24, 2022. It will specifically contribute to Objective 4 “improving access to basic service delivery in vulnerable areas” of Country Partnership Framework (CPF) Focus Area 2 “Strengthening Service Delivery to Protect the Poor and Vulnerable” by expanding access to a basic package of essential health services and to a package of high-complexity and high-cost services. The Program also contributes to Objective 5, “improving human capital of vulnerable populations”, by strengthening access and quality of public health services. Finally, the Program is also well aligned with Objective 6, “improving governance and transparency”, as it will: (i) improve coordination and harmonization across levels of care and across the different health subsystems (i.e., social security, public, and private); and (ii) support activities to institutionalize performance-based financing mechanisms for those provinces and health providers supported by previous operations. 25. This Program also follows the directives of the Latin America and the Caribbean Roadmap for Climate Action 2021-25 which guides the World Bank’s “response for scaled-up, transformational climate action in the region”. In alignment with the Roadmap, the PforR will support measurable improvements in climate change adaptation and resilience by including investments to improve the infrastructure and energy efficiency standards of healthcare facilities and the preparedness of healthcare facilities for natural disasters through Disbursement- linked Indicator 5 (DLI 5). Furthermore, the Program is aligned with the National Plan for Climate Change Adaptation and Mitigation, and the health-related Sector Program. It will support the development and approval of the Implementation Strategy for advancing the above-mentioned Plan and its adoption for the provinces (DLI 9). 26. The PforR is the most appropriate financing instrument to support the NIHP. The PforR promotes the use of country systems, thereby consolidating different programs and projects with different fiduciary and 39 Report No. 131971-AR, World Bank. 40 Report No. 170668-AR, World Bank. Page 17 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) monitoring arrangements. The PforR is the right instrument to institutionalize successful health reforms that the World Bank has been supporting for many years, using result-based transfers between the Federal Government and the provinces. The MSN is developing all the mechanisms and tools needed at the national and provincial level so that programs like Sumar and Proteger will continue and be fully institutionalized within government systems. This requires financial, governance, and fiduciary reforms, which will be supported under Results Area (RA) 1. Although the first time used in the health sector, the Government is familiar with the instrument that is currently being implemented in the education41 and water sectors.42 II. PROGRAM DESCRIPTION A. Government Program 27. According to the federal system and regulatory framework, the MSN is responsible to oversee, regulate and manage the entire health system. The MSN is also responsible for national-level programs to improve equity and quality of health services, and the design and implementation of policies to optimize the system overall. Provinces, through the MSP, have the primary responsibility for service delivery and financing, as well as managing government health services. In turn, the municipalities (local level) oversee the execution of national and provincial programs. In some provinces, like Buenos Aires, Córdoba, and Santa Fe, municipalities are responsible for service delivery and financing. The roles and functions of the MSN include: (i) formulation and evaluation of health policies, plans, programs and projects; (ii) promotion of healthy habits in the population; (iii) prevention of endemic diseases and NCD; (iv) development of human resources and talent in the health sector; (v) health surveillance; (vi) preparedness and emergency response; (vii) climate change adaptation and mitigation strategies related to the health sector; (viii) health systems, national records for health, and digital health agenda; (ix) development of clinical guidelines and protocols; and (x) formulation, adoption, and evaluation of policies related to pharmaceuticals, medical devices and supplies, biomedical technology, and service delivery. The MSN interacts with the MSP within the framework of the Federal Health Council (COFESA). 28. The NIHP responds to structural problems and emerging challenges of the health system in Argentina, and “contributes to the development of an integrated, equitable and sustainable health model, which guarantees the effective coverage of comprehensive healthcare services”. The specific objectives mentioned in the NIHP are to: (i) increase effective and equitable coverage of prioritized health services and care lines, under the criteria of quality, transparency, and efficiency; (ii) improve the integration and continuity of care by strengthening healthcare networks; (iii) support the integration and coordination between the public, private, and social security sectors, through the progressive harmonization of the health services packages; and (iv) 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. 29. The NIHP is built around five pillars: (i) Equitable access to healthcare; (ii) Quality of healthcare; (iii) Efficiency; (iv) Integration and health services networks; and (v) Health intelligence. Furthermore, the Plan’s activities are structured around eleven strategic lines (Figure 2). 41 Loan IBRD 8999-AR Improving Inclusion in Secondary and Higher Education Program (P168911). 42 Loan IBRD 9207-AR Buenos Aires Water Supply and Sanitation with a Focus on Vulnerable Areas Program (P172689). Page 18 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Figure 2. NIHP Pillars and Strategic Lines Note: Grey highlighted boxes illustrate the boundaries of the program supported by the PforR. Source: National Integrated Health Plan 2023-2028, MSN 30. The MSN has assigned a budget to each of the 11 strategic lines of the NIHP, which include 14 programs and 29 activities or budget lines. The NIHP has a projected budget of US$920 million for 2023, which represents approximately 51 percent of the MSN administrative budget (US$1,791 million, without decentralized agencies). The estimated budget allocated to the NIHP during the three-year support (2023-2025) of the PforR is US$3,072 million. B. Theory of Change 31. The proposed PforR will support investments and activities to i) increase equitable and effective coverage for health services under selected lines of care offered by public health facilities; and ii) obtain efficiency improvements through coordination and integration of health subsystems and climate change actions. For RAs 1 and 2, direct beneficiaries are the people without formal health insurance that rely exclusively on the public health system (19.9 million people as of January 2023).43 However, the entire population of Argentina (46.04 million)44 will benefit from the functional integration and coordination of different systems and overall quality and efficiency. Promoting quality standards of care, developing regulations to reduce NCD’s risk factors, harmonizing a package of cost-effective services, promoting efficiencies in the purchasing of essential drugs including digital prescription, promoting adaptation and mitigation measures to climate change. 32. For each of these RAs, the Program proposes activities to improve institutional processes and health services and defines outputs needed to achieve the Program Development Indicators (PDIs) (see Figure 3). To this end, RA1 is a cross-cutting area that supports the legal and regulatory framework as the foundation of the PforR, in terms of consolidating and institutionalizing results-based health financing mechanisms used by ongoing World Bank financed projects at the national and provincial levels. In this regard, this RA1 will enable the MSN to purchase a package of health services defined under the criteria of quality, efficiency, and financial protection to the MSP, for those without formal health coverage. The other RAs address the main challenges of: (i) inequalities 43 Population enrolled at Sumar Program and registered in the MSN’s Health Integrated Information System (SISA). 44 2022 National Census, provisional data as of April 2023 (INDEC) Page 19 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) in the coverage and timely delivery of quality basic services to the eligible population (RA2); (ii) an inadequate care model to address the country’s evolving and NCD-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 (iii) the weaknesses in the efficiency use of health resources due to the highly fragmented and decentralized nature of the health system and promoting climate change related measures (RA4). 33. Furthermore, RA2 and RA3 have a strong focus on equity with the aim to improve the delivery of relevant care for those underserved 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 vaccines and NCD prevention, screening, and care (with an emphasis on breast cancer, mental health, and GBV victims 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 the quality of care 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, RA3 also aims to improve effective coverage, particularly of NCD services such as breast cancer treatment. Therefore, RA3 will also support the National digital health system and the interoperability strategy, as a precondition for care coordination. Page 20 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Figure 3. Theory of Change (See sequencing of PforR supported activities in Figure A3.2) Page 21 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Page 22 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) C. PforR Program Scope 34. The proposed PforR will support four out of five pillars of the NIHP, the Government’s program (see Figure 2). As mentioned before, the three NIHP objectives are organized in five pillars. For each pillar of the NIHP, there are specific strategic lines and activities. The PforR will support specific strategic lines and activities linked to RAs that provide the boundaries of the program. These are the following strategic lines and activities: 1) institutionalization of the Sumar Program; 2) gender diversity and GBV; 3) mental health promotion; 4) quality of integrated healthcare with evaluation of health facilities; 5) quality for health promotion and regulations linked to reducing NCDs risk factors; 6) strategic purchase of drugs; 7) roadmap for the definition of the integrated health services package (PAISS), 8) implementation of PAISS; and 9) health information systems (see Table A3.1 in Annex 3). This selection of these specific strategic (and budget) lines was made based on the development objectives of the PforR during the three-year implementation period, based on the World Bank’s long-term and ongoing support, and historically high levels of execution to ensure an adequate flow of funds. 35. Results Area 1: Consolidated and institutionalized health financing mechanisms. The activities under RA1 establish mechanisms and processes that set the basis for the other RAs. This RA will support the Page 23 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) strengthening of the MSN and MSPs purchasing capacity, through the consolidation of financial transfer mechanisms to the MSPs and the refinement of payment modalities for purchasing cost-effective health services by participating healthcare providers (including results-based schemes). To this end, RA1 is designed to set the foundation for the implementation of interventions and results under RA2 and RA3. Disbursement-linked Results (DLRs) under RA1 are related to approval of norms, regulations, and framework agreements required for the implementation of the Program. In addition, RA1 institutionalizes the Sumar and Proteger programs and provides continuity to the mechanisms implemented. RA1 provides the basis for RA2 and RA3, each of which includes a DLI and PDI related to the population that receives effective basic healthcare in the public sector, and women diagnosed with breast cancer that receive timely treatment. Both indicators have been measured by the Sumar Program (see Box 2). Box 2. Effective Coverage - Tracking Real Progress towards UHC Achievement The concept of effective coverage goes beyond measuring enrollment status in an insurance scheme or timely access to services. It measures actual utilization of high-quality and priority healthcare services during a defined period (i.e., during the last year). Only the utilization of priority healthcare services provided according to well-defined clinical guidelines and protocols counts towards the fulfillment of effective coverage. This explicit focus on the quality of delivered services is needed, as improvements in access to and the utilization of health services do not necessarily translate into health gains without that explicit focus. The World Health Organization (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”[1] [2]. Effective coverage is a more ambitious indicator than general or “simple” coverage which measures the percentage of people that receive any service. Due to its ambition, effective coverage has been termed a new approach to properly assess health system performance[3]. However, measuring a person’s need for healthcare services as well as the actual quality and effectiveness of healthcare services is not without challenges and needs to be proxied. Likewise, comparing indicators of effective coverage across different countries and healthcare systems is challenging, as benefit packages and systems differ considerably. The Trajectory of Effective Coverage under the Sumar Program. Under the Sumar Program, a subset of relevant health services that considers the age and sex group-specific burden of disease and disease prevalence’s were considered towards the achievement of effective coverage. For any healthcare service to be considered towards effective coverage, auditable clinical guidelines and quality standards were defined and needed to be complied with. In total, the package of interventions that counted towards basic effective coverage under the Sumar Program contains 700 basic interventions that are mainly delivered in primary healthcare. These include general health, prenatal, ophthalmological, dental and gynecological check- ups, and routine childhood immunizations mammographies and PAP smears among others. Effective coverage was 7 percent, when the Sumar Program started in 2013 and expanded the scope to include additional population groups and health services included in the Nacer Program. Over the last ten years, effective coverage of the otherwise uninsured population has become a central indicator for the MSN to measure progress towards universal health coverage in the public health sector. For effective coverage, a beneficiary of the Sumar program must be enrolled in the program – in other words, lack formal health insurance – and receive healthcare services during the previous 12 months. Capitation payments to provinces are based on the number of enrolled beneficiaries with basic effective coverage. Over time, the number of eligible beneficiaries has steadily increased. Despite disruptions during the pandemic, the number of beneficiaries of the Sumar program increased from five million to six million in mid-2022. It is important to mention that improving effective coverage is challenging, as the target group is mostly underserved and hard-to-reach population groups that are less likely to actively seek the health services they need. In addition, the benefit package is limited to essential services and does not reflect more specialized services and hospital-based care. [1] PAHO. (2021). Assessing barriers to effective coverage with health services. [2] Shengelia, 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. [3] Ali Jannati, 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. Page 24 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 36. Results Area 2: Increased equitable and effective coverage of public health services for the eligible population. This RA will seek to increase equitable and effective coverage of key health services (defined under RA1) delivered with quality standards in a timely manner, recover losses during the COVID-19 pandemic, and increased effective coverage for the population using the the public health services. This RA will close the gaps with a special focus on prevention and control of chronic conditions, such as breast cancer; improving screening and control of mental health; services related to GBV victims; and high complexity services for children, such as pediatric cancer. In addition, this RA will 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 will increase NCD screening among men, and will 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 program. 37. Results Area 3: Improved quality and integration of care in the public sector. This RA will support the government in implementing measures to improve the quality and integration of health services, and coordination and continuation of care. It is related to area 2 (quality) and area 4 (integration) of the NIHP. Activities included under this RA are (i) 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; (ii) support the accreditation of mammography centers for quality;45 (iii) actions to georeferencing of orientation teams to recognize, manage, and refer GBV victims to the appropriate services; (iv) strengthen the timely treatment of women diagnosed with breast cancer and the adoption and implementation of an integrated pediatric cancer network; and (v) the development and implementation of standards to share clinical information between health providers across jurisdictions as a precondition for quality and continuation and coordination of care. RA3 will also manage the citizen claims and complaints. Finally, this RA will promote regulatory actions by the MSN and MSP to protect people against NCD risk factors, such as the implementation of a labeling law to prevent NCDs. 38. Results Area 4: Improved efficiency through the coordination and integration of health subsystems. This RA is related to area 3 (efficiency) and area 4 (integration) of the NIHP and will 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 across different subsystems. Among other activities, it will include actions to: (i) design and implement an integrated benefit package with protocols and standards of care, advancing the PAISS for the health system overall; (ii) improve the efficiency of pharmaceutical inventory through digitalization; and (iii) support capacity development for the centralized purchasing of essential medicines, producing savings in its purchase against the retail price. Furthermore, this RA 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 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 and Climate 45In 2022, the INC published the Manual for the evaluation of quality and safety standards in breast diagnostic services https://bancos.salud.gob.ar/sites/default/files/2022-12/2022-12-Manual_Calidad_Seg_en_Diagn%C3%B3stico_Mamario.pdf Page 25 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Change, and the related adaptation plans, will create the necessary conditions for the future implementation of more cost-effective interventions in terms of linking financing with climate vulnerabilities. Table 3. Boundaries of the PforR compared to the NIHP (Government Program) Government program Program supported by Reasons for non-alignment the PforR Objective Contribute to the Support improvements in The PforR will support a set of activities development of an the effective and related to the institutionalization of integrated, equitable, equitable coverage of mechanisms already implemented by and sustainable health public health services, the Sumar and Proteger Programs, and system that guarantees and the efficiency of the three MSN initiatives: PAISS, the effective coverage for a health system through National Strategy for Quality, and comprehensive package better coordination and Remediar Program for purchasing of of quality health services. integration. essential medicines.46 Duration 2023-2028 2023-2025 The PforR will support the first three years of NIHP implementation, as a transition from World Bank funded project to a national program. Geographic The entire country The entire country coverage RAs Areas 1 to 5 Areas 1 to 4 The selection has been made based 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$3,072 million US$1,713 million, of The MSN has prioritized 10 budget Financing which US$300 million of programs and 14 budget activities IBRD financing under the PforR amounting to US$1,713 million. 39. Building on the successful engagement in the health sector over the last decade, the World Bank and the Inter-American Development Bank (IDB) will provide separate financing for the NIHP between 2023 and 2025. The IDB financing is complementary to the World Bank financing; both support the common goal of the NIHP, but finance different strategic budget lines and activities. Specifically, the IDB will continue to finance the Redes Program.47 This coordinated arrangement has worked successfully in the past, as the IDB operations have focused on supporting the developing of care networks and pharmaceutical procurement, which are not included 46 Remediar National Program: MSN’s program for purchasing essential drugs according to an approved methodology (Presidential Decree 2724/2002, MSN Resolution 248/2020, MSN Resolution 1048/2021) 47 Redes 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 healthcare networks through the integration and coordination of health facilities and teams in all country provinces. Page 26 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) in the PforR. If any activity would receive financing from IDB or another development partner, this contract would be excluded from the expenditure framework of this PforR. 40. The PforR also builds on the World Bank’s analytical work with the MSN on issues related to quality of care, as well as the integration and efficiency of the health sector. This includes technical assistance to institutionalize the Sumar Program and further strengthen its design financed by the primary healthcare Performance Initiative. The Initiative is a partnership between the World Bank, the Bill and Melinda Gates Foundation, and the WHO that focuses on: (i) evaluating the effectiveness of different payment modalities for healthcare services from provinces to public care providers with funds from the Sumar Program; and (ii) recommending possible adjustments and refinements to these payment modalities and the monitoring and evaluation arrangements to be implemented under the Program. The World Bank also has been providing technical assistance to the MSN, MSP, and the INC on the formalization of a high-complexity and 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 support includes the implementation of a health system strengthening program that provides training to high-level officials of the MSN and MSPs focusing on the integration of the health system. D. Program Development Objective(s) (PDO) and PDO Level Results Indicators 41. 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 universal health coverage through the development of an integrated health system. 42. The beneficiary population of the PforR is mainly the population without formal health insurance that exclusively relies on the public health system in all provinces (19.9 million people as of January 2023). In addition, as explained above, RA3 and RA4 will benefit the entire population (46.04 million people as of 2022). 43. The proposed PDO indicators are directly associated with the Program’s development objectives: (i) For equitable and effective coverage: Percentage of population with basic effective coverage.48 (ii) 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). (iii) For efficiency: Savings in the purchase of essential medicines relative to the retail price at the time of the award. E. Disbursement Linked Indicators and Verification Protocols 44. Results Area 1: Consolidated and Institutionalized health financing mechanisms. This RA will support the consolidation and institutionalization of health financing mechanisms which foster increased access to quality healthcare services for the population without formal health insurance. The Government will seek to achieve two specific results related to this RA1 and its DLI: (i) ensuring the existence of mechanisms to transfer financial resources linked to results from the MSN to the MSP in the form of result-based capitation payments following the Sumar Program mechanism. These funds will finance the provision of a package of cost-effective health services with quality protocols to the population without formal insurance, to close gaps in equity and quality 48 See Box 2 for the definition of effective coverage Page 27 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) access; and (ii) harmonize and unify different MSN financial transfers to the provinces, such as those with incentives for quality of care, following the Proteger Program logic, among others. DLI 1 and its DLR under RA1 will measure the issuance of a norm establishing the results-based transfer mechanism, the creation and maintenance of a budgetary line for this purpose, and the number of provinces that signed the Participating Agreement that enforces the compliance with the arrangements related to the institutionalization and implementation of the NIHP. In this regard, RA1 includes foundational Prior Results and early signing of Framework Agreements with the provinces. Table 4. Results Area 1 (US$38 million) DLI 1. Consolidated and institutionalized health financing mechanisms (US$38 million) DLR 1.1: Administrative act for the integrated transfer mechanism from the Nation to the Provinces and its related Annexes approved (Decree, Resolution) (Prior result).49 This should include: (i) description of the methodology for calculating the integrated transfers, including the methodology to calculate the capita value (based on the costing of a cost-effective benefit plan (currently the Sumar benefit package and in the future that which is aligned to the PAISS and the definition of the population without formal health coverage on which the total transfer will be calculated (currently based on those enrolled under the Sumar Program); (ii) the description of the financial flow incorporating the three levels: Nation, Province and health facilities; (iii) the payment modalities to health facilities for the health services delivered to the enrolled population (currently the Provincial Nomenclature valued); (iv) the roles and functions of each party involved in the process; (v) the mechanism for reporting the use of funds (from province to Nation); (vi) the obligations set out for in the Program Action Plan and the Anti-corruption Guidelines; and (vii) the corresponding sections of the participating agreement model to be signed between the Nation and the Province and between the Province and the Health Provider. DLR 1.2: Annual creation of Budgetary Line for NIHP including the financial integrated capitation transfers (Milestone in year 1 and recurrent in subsequent years). During the first year, the indicator will inform on the MSN’s request to the National Budget Office (ONP) to open a programmatic category in Administrative and Financial Services (SAF) 310’s budget and the notification of its granting. In the following years, it will monitor the maintenance of the programmatic line for NIHP, and verifying the credits assigned for the execution corresponding to the financial integrated capitation transfers under the NIHP. (Source: Integrated Financial Information System Internet (e-SIDIF)) DLR 1.3: Number of Provinces with signed sections of the Participation Agreement that pertain to the Program (scalable 2023-2024) DLR 1.4: Administrative act for the creation of a National Fund for high-complexity diseases based on the institutionalization of the National Fund for Equity in Health (FONES) mechanism (Decree, Resolution) (Prior result).50 45. Results Area 2: Increased equitable and effective coverage to health services. This RA will support the implementation and follow up of the result-based transfers designed under RA1, strengthening the MSN in its functions of purchasing a defined package of health services (essential and high complexity) for the population without formal health insurance. To this end, DLI 2 will support the continuation of the PDI indicator under the Sumar Program, related to the percentage of eligible population (those without formal insurance) with effective 49 Expected to be accomplished prior to effectiveness. The MSN’s technical team has prepared an administrative act that is under the revision of high-level authorities. 50 Expected to be accomplished prior to effectiveness. The MSN’s technical team has prepared an administrative act that is under the revision of high-level authorities. Page 28 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) coverage to selected cost-effective health services, mainly focused in NCD-prevention and control, maternal and childcare, mental health, GBV survivor related services, reproductive health, among others. 46. RA2 will also emphasize on recovering health coverage and outputs negatively affected by the COVID- 19 pandemic. Specifically, DLI 3 will focus on MMR routine vaccine coverage and its appropriate registration. The immunization rate registered at individual level had a 15-percentage-point drop in 2020 compared to 2015 and a 12-percentage-point drop compared to 2019.51 As a result, in 2020, Argentina had the largest measles outbreak since the elimination of endemic circulation was recorded, with 174 confirmed cases, including one death. Furthermore, the Federal Vaccination Registry (NOMIVAC) manages the vaccination coverage of the whole country and allows the registration of each vaccine application to each person (detailing the date, dose, lot and establishment, among other relevant data). With this approach, the objective is to keep updated and available all the doses received by each citizen. This computerized management model through a personalized registry provides all health facilities with the possibility of having updated, consistent and reliable data. Moreover, it offers citizens access to their records, where they can consult their own up-to-date vaccination history. In addition, this information converges with other health data that are also managed in the Citizen’s Record, which centralizes the different records associated with the same citizen in a single, individual repository. In this way, the uniqueness of the identification data of individuals is guaranteed, which can be kept up to date and can be permanently consulted from the system. Also, DLI 3 is related to healthcare services included under the benefit package of the Sumar Program. Table 5. Results Area 2 (US$95 million) DLI 2. Population with basic effective coverage (US$47 million) DLR 2.1: Population with basic effective coverage Incremental indicator up to a maximum to 41 percent, using the operational definition currently implemented by the Sumar Program DLI 3. Coverage of children with MMR vaccination registered at individual level (US$48 million) DLR 3.1: Personalized registry dose applied at school entry Incremental indicator up to a maximum of 85 percent (pre-pandemic coverage value) using NOMIVAC as a source of information. 47. Results Area 3. Improvements in the quality and integration of care in the public sector. DLIs in this RA will contribute to improvements in quality and integration of care in the public sector, building on the previous World Bank-supported projects. In this regard, DLI 4 will focus on timely treatment of breast cancer and its appropriate registration, since breast cancer is the first cause of death by tumors in women in Argentina,52 and while early detection is critical for improving breast cancer outcomes and survival, once diagnosed, the care of people with cancer requires moving from a reactive model, centered on the disease, to a proactive and planned model, centered on the person and their context. To this end, DLI 4 will support improvements in the percentage of women with diagnosed breast cancer that receives timely treatment and is registered in MSN systems; DLI 4 is related to healthcare services and a tracer indicator included under the benefit package of the Sumar Program. 51https://www.unicef.org/argentina/media/13186/file/Coberturas%20de%20vacunaci%C3%B3n,%20un%20desaf%C3%ADo%20para%20e l%20pediatra.pdf 52 Considering all tumor sites - except for non-melanoma skin cancer - the age-adjusted incidence rate (world) places Argentina among the countries in the world with medium-high cancer incidence. WHO: https://gco.iarc.fr/today/data/factsheets/populations/32-argentina-fact- sheets.pdf Page 29 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 48. In addition, previous work under the Proteger Program has contributed to enhancing the care of patients with NCD. One of its main achievements has been improving the readiness of public health facilities to deliver higher quality NCD-services for underserved population groups and expanding the scope of selected services.53 These actions have resulted in 1,166 primary healthcare facilities certified for the detection and control of NCD. One of the goals under this RA3 is to continue improving and expanding quality assessments, to secondary level facilities and to new health dimensions such as mental health, gender and diversity perspectives, patient safety, quality management and risk management, and environmental and climate change adaptation standards. Furthermore, RA3 will support regulations that promote better coordination of care such as the establishment of the pediatric oncology network. 49. In this regard, DLR 5.1 will build directly on the Proteger Program and support further quality improvements in primary healthcare by supporting the administrative act to create a new primary healthcare Quality Tool. The MSN has been working on a new tool defining the processes and standards for recognizing facilities committed to quality at primary level, to incorporate these facilities into the National Health Quality Plan.54 This primary healthcare tool will include requirements to comply with 92 different standards organized in four main areas: (i) overall organizational set-up of the facility, (ii) management of human resources, (iii) quality assurance, and (iv) patient safety. These areas include, but are not limited to, elements related to the detection of women that suffered GBV, quality guidelines for referrals and counter-referrals within primary healthcare, and evaluation of user’s satisfaction. The quality tool also includes environmental standards and standards related to climate adaptation measures. Examples of the former include location and civil works standards, electricity and water, pathogenic waste management, human resources, and patient security; examples of climate adaptation measures include presence of climate emergency preparedness and response plans, surveillance of climate- sensitive illnesses including injuries due to extreme weather events, diseases exacerbated by high temperatures, vector- and water-borne infectious diseases. In fact, 22 of the 92 areas will evaluate the implementation of climate adaptation measures. The support of the PforR to increase quality of public primary healthcare services will benefit groups that are highly underserved to the impacts of climate change, including mothers, children, the poor, the elderly and people with disabilities. 50. DLR 5.2 will contribute to ensuring that inpatient healthcare facilities are evaluated and certified as facilities committed to quality and climate standards and receive adequate support to keep working on related goals. Specifically, this DLR will support the process through which inpatient public health facilities’ commitment to quality is recognized as established by MSN Resolution 1744/21.55 DLR 5.2 will monitor the number of facilities at secondary level that meet established quality standards. These standards will be measured by 59 evaluation measures, including measures to increase the resilience of the health system to observed and anticipated climate change impacts. The climate adaptation standards will include 26 (out of 59) specific measures to: (i) ensure 53 The Proteger Program supported: (i) the implementation of systematic assessment tools focusing on the delivery of NCD services in primary healthcare facilities with result-based financing; (ii) the development of provincial plans for an integrated approach toward NCD detection and treatment and underlying risk factors; and (iii) NCD training to health staff at the provincial level. 54 The MSN in 2019 adhered to the Strategy and Plan of Action to Improve the Quality of Care in the Delivery of Health Services 2020- 2025, approved at the 57th Directing Council of PAHO and created the National Health Quality Plan 2021-2024 to strengthening governance and quality and effective coverage of health services. 55 MSN Resolution 1744/21 approved in 2021, mandates that for accreditation the following steps must be taken: (i) the identification of a multidisciplinary team per facility and the formation of a quality committee, (ii) the completion of a self-assessment that includes 59 criteria – essential, necessary, and recommended – and be sent to the quality management through the computer system, so that it can perform the verification. According to the total criteria, the facilities are certified and an action plan with corrective and preventive actions is developed. Page 30 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) facilities are able to deal with extreme heat events through effective insulation and shading; (ii) ensure facilities are equipped to respond to wildfires with axes and fire beaters, as well as having ambulatory facilities able to deal with these threats; (iii) provide facilities with emergency electric power services to ensure continuity of health service provision during power outages due to floods and heatwaves especially for critical services such as operating rooms, intensive care units, and neonatal and pediatric services; (iv) develop emergency and evacuation plans in the face of climate-related hazards; (v) implement maintenance and preventive measures at the facility level to ensure safe and adequate infrastructure that complies with building and operation standards for climate change adaptation and disaster response; (vi) improve primary healthcare services for the prevention, diagnosis, and treatment of climate-sensitive illnesses and injuries due to extreme weather events, high temperatures, vector- and water-borne infectious diseases, respiratory illnesses; (vii) improve drainage to reduce risks of flooding and stagnant water which can increase the risk of waterborne infections; and (viii) emergency management plans to deal with extreme weather events. 51. DLR 5.3 will support the creation of the pediatric oncology network, for improving quality and coordination of care of pediatric cancer. Late diagnosis and lack of adequate follow-up to allow treatment to be administered appropriately are two main factors for relative worse-off results for pediatric cancers in Argentina. Although childhood cancers encompass low-frequency pathologies, these are of high morbimortality that require diagnostic and therapeutic strategies of high specificity.56 The current pediatric oncology informal network is nourished by the actions of existing public organizations: the Integrated Health Services Networks (RISS) strategy (Pan American Health Organization, PAHO), the primary healthcare strategy and the Sumar Program. In 2000, the Argentine Hospital Pediatric Oncology Registry (ROHA) was created to unify childhood cancer registries in the country. With the aim of formalizing a pediatric oncology care network that allows comprehensive care in a coordinated manner, since the end of July 2021, the National Directorate for Strengthening Provincial Systems, the National Directorate for Quality in Health Services and Health Regulation, the Prof. Dr. Juan P. Garrahan Hospital and the INC began to work together to draw up a roadmap to move forward in the establishment of the Argentine pediatric oncology network. The governance of the network should be based on two instruments: (i) a regulatory framework that contemplates and regulates every aspect of the network and is exercised by the MSN through an institutional space created for this purpose; and (ii) the Pediatric Cancer Coordinating Center, whose responsibility will be to manage the network. Specifically, DLR 5.3 will focus on the administrative act regulatory framework to create the network. Table 6. Results Area 3 (US$63 million) DLI 4. Timely breast cancer treatment and registration (US$23 million) DLR 4.1: Women aged 30-74 with diagnosed breast cancer that receive timely treatment (as registered at individual level) Numerator: Number of eligible women aged 30-74 years that initiated treatment for breast cancer in the last year. Denominator: Estimated number of new cases of eligible women aged 30-74 years with breast cancer. Eligible women are those with exclusively public health coverage. Source: Screening Information System (SITAM) and/or the Argentina Institutional Tumor Registry (RITA) and/or Sumar Health services database DLI 5. Implementation of Quality and Climate Standards for Healthcare Facilities (US$40 million) DLR 5.1: Administrative act of creation of the Quality Tool for primary healthcare which includes Climate standards. Administrative act of creation by means of a normative instrument to be defined (Decree, Resolution). 56 INC Report 2021 Page 31 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLR 5.2: Inpatient public health facilities certified as facilities committed to quality which includes climate standards according to MSN Resolution 1744/21. Incremental indicator up to a maximum of 135 inpatient public facilities (excluding mental health and geriatrics) out of a total of 1,368. DLR 5.3: Creation of the pediatric oncology network. Administrative act of creation by means of a normative instrument to be defined (Decree, Resolution) (Prior result) 52. Results Area 4. Improved efficiency through coordination and integration of health subsystems. DLIs under this RA will support improvements in the efficiency of health expenditure through: (i) the strengthening of centralized procurement arrangements to produce savings in the purchase of a package of essential medicines relative to the retail price; (ii) the design and implementation of an integrated health benefit package with protocols and standards of care, advancing the PAISS for the health system overall; and (iii) improvements to the efficiency of pharmaceutical inventory through digitalization of prescriptions. Furthermore, this RA4 will focus on the regulatory framework necessary to implement climate change adaptation and mitigation strategies, thereby 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 the carbon footprint of the health system and its contribution to Greenhouse gases emissions. 53. DLI 6 under RA4 will support the review of the methodology for essential drugs purchasing at the central level and savings in the purchase of those drugs relative to the retail price . Technological advances are a key driver of health expenditure growth, involving both diagnostics and treatments, which in turn include pharmacological and non-pharmacological interventions.57 Argentina has been significantly impacted by inflation, the interannual variation in prices of medicines rose to 88.4 percent as of January 2023. 58 The lowering of prices of essential medicines through a variety of measures such as pooled and collaborative procurement at the national (or even supranational) level is a result to be achieved under RA4. 54. DLI 7 under RA4 will support efficiency gains through the adoption of an explicit health benefit package applicable for all health sectors, based on care protocols and costed lines of care, with defined mechanisms for the updating of the benefit package and the incorporation of new technologies (DLI 7). A well-defined health benefit package helps ensure that the entire population has access to a similar set of essential healthcare services regardless of their socioeconomic status or ability to pay and thereby promotes health equity by reducing disparities in access to care. The proposed PAISS benefit package provides a clear definition of the services that are covered. Lines of care have been selected based on four criteria (population disease burden, equity in access, potential benefits and severity of disease) and for each line care to be included in the PAISS, every healthcare service is subject to a cost-effectiveness evaluation. This approach helps policymakers to allocate resources more efficiently and effectively according to a transparent process, thereby creating accountability. Currently, there is no such explicit general benefit package in Argentina59 and, as a result, the selection of what to finance does not 57 Rozmarinová, J. 2020 Health Technology Assessment. Literature Review. Current Trends in Public Sector Research. Proceedings of the 24th International Conference https://doi.org/10.5817/CZ.MUNI.P210-9646-2020-12 58 Dirección de Economía de la Salud 2023. Seguimiento de precios de medicamentos en el mes de enero 2023 - Informe Inmediato -. https://www.argentina.gob.ar/sites/default/files/2023/01/informe_variac_medicam_enero_2023-_622023.pdf 59 The Mandatory Medical Program supervised by the MSN, serves as a regulatory framework established by the Federal Government to ensure that all Obras Sociales offer a minimum package of medical services and benefits to their members, but it does not apply to the public sector. With respect to the public sector, the MSP and the MSN provide and finance - with different degrees of coverage and with Page 32 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) always follow clear prioritization criteria leading to little efficiency in the management of resources. To this end, the PAISS has the potential of aligning the public sector and the social security sector in terms of their service delivery structure. The proposed PAISS also builds on the experience of the Sumar Program's Health Benefit Plan, which specifies which health services are prioritized for the beneficiary population based on a cost-effectiveness analysis and the national epidemiological profiles. 55. DLI 8 will support the Digital Prescription Strategy implementation. Digital prescriptions will improve efficiency and quality of care by decreasing prescription errors and preventing adverse effects. International evidence suggests that the implementation of digital prescriptions is associated with 50 percent reductions in prescribing errors.60 Medication errors are mainly caused by lack of legibility and lack of completeness of prescriptions. These issues are rectified by digital prescriptions. In addition, digital prescriptions can help reduce order-processing times and healthcare costs.61 DLI 8 will approve the administrative act for digital prescriptions that establishes that it should use the international standards to allow information exchanges among different actors through the National Digital Health Network and creates the Federal Health License which will include all the qualifying registrations of health professionals in the Federal Network of Health Professional’s registry. This license will determine a unique ID for the health professional to access other interoperable systems as well, allowing the implementation of Information and Communication Technologies in the Health System. In this sense, this strategy also favors the integration of health professionals of the different sectors. This strategy thereby also promotes an interoperable digital infrastructure with federal scope that strengthens the exchange of health information for providing better health quality services to the population. 56. Finally, DLI 9 will support efficiency enhancements linked to climate change adaptation and mitigation strategies. DLI 9 intends to strengthen the regulatory framework necessary to implement Argentina’s climate change adaptation and mitigation strategies to promote an efficient health system response to climate change in line with the National Plan for Climate Change Adaptation and Mitigation and following the creation of the Climate Change Program under the MSN (MSN Resolution 555/2021). DLI 9 will finance (i) a ministerial resolution creating the National Strategy for Health and Climate Change that will detail the steps to operationalize the National Plan for Climate Change Adaptation and Mitigation and serve as the umbrella norms for climate change adaptation and mitigation in the health sector; and (ii) the development of Provincial Plans for climate change adaptation and mitigation in each jurisdiction. These adaptation plans will create the necessary conditions for future implementation of more cost-effective interventions to finance activities to reduce climate vulnerabilities. Table 7. Results Area 4 (US$103.25 million) DLI 6. Savings in the purchase of essential medicines (US$39.25 million) DLR 6.1: Integral analysis and revision of the package of essential medicines This indicator has the objective to support the integral analysis and revision of the package of essential medicines being purchase by Remediar Program. The revised methodology will be approved by an Administrative Act. DLR 6.2: 70 percent savings in the purchase of essential medicines relative to the retail price at the time of award few explicit prioritization mechanisms (such as under Sumar Program), healthcare services, medicines and supplies through different Directorates, Programs or Plans. 60 Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. J Am Med Assoc 1998; 280:1311-1316. 61 Esmaeil Zadeh, P., & Tremblay, M. C. (2016). A review of the literature and proposed classification on e-prescribing: Functions, assimilation stages, benefits, concerns, and risks. Research in Social and Administrative Pharmacy, 12(1), 1-19. https://doi.org/10.1016/j.sapharm.2015.03.001 Page 33 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) MSN has purchased the revised package of essential medicines with at least seventy percent (70 percent) savings in relation to the retail price at the time of the award DLI 7. Argentina’s Integrated Health Services Plan (PAISS) (US$21 million) DLR 7.1: Approval of PAISS Administrative act of institutionalization of the PAISS. It is recommended that this act includes: (i) costing of the lines of care of the benefit package and evaluation of its financing; (ii) design of mechanisms for updating the lines of care, benefits and costs included in the country's benefit plan; (iii) protocols and care guidelines developed according to the needs foreseen for the PAISS; and (iv) protocols and care guidelines developed according to the needs foreseen for the PAISS. DLR 7.2: Implementation of PAISS Administrative act with the approval of the roadmap for the implementation of PAISS. The Action Plan will include the actions and timeline for working with the other subsystems of the health system to implement the PAISS. DLI 8. Administrative Act for Digital Prescription (US$10 million) DLR 8.1: Digital Prescription Approval Decree regulating Law 27,553 on electronic or digital prescriptions, which systematizes definitions, requirements, responsibilities, and details, on digital prescription and of the platforms regulated by the law. (Prior Result) DLI 9. Adaptation and mitigation strategies for climate change (US$33 million) DLR 9.1: Administrative act approving the Health and Climate Change Strategy Administrative act that approves the Health and Climate Change Strategy. This act is a joint effort between the MSN and the Ministry of Environment and Sustainable Development. Ministerial administrative act includes: (i) scope of the strategy; (ii) main activities; (iii) responsibilities for each actor; (iv) link to main principles and goals established in the National Plan for Adaptation and Mitigation to Climate Change (Prior Result). DLR 9.2: Number of provinces with provincial health and climate change plans approved MSP’s administrative acts on approved climate change plans to include at least the following elements: (i) creation of climate change working groups in the MSP; (ii) measures for improvement of climate-sensitive vector- borne diseases (VBD) surveillance; (iii) measurement of the carbon footprint at the hospital level. 57. A summary of the four RAs and each DLIs including the Global Crisis Response Framework tagging is shown in Table 8. Table 8. Summary of RAs and DLIs, including Global Crisis Response Framework (GCRF) Pillar Loan Amount No. of GCRF Results Areas (US$ million) DLRs Pillar Results Area 1: Consolidated and Institutionalized health financing mechanisms. DLI 1: Consolidated and institutionalized health financing mechanisms 38.00 4 4 Results Area 2: Increased equitable and effective coverage to health services. DLI 2: Population with basic effective coverage 47.00 1 2 DLI 3: Coverage of children with MMR vaccination registered at individual level 48.00 1 2 Results Area 3: Improvements in the quality and integration of care in the public sector. DLI 4: Timely breast cancer treatment and registration 23.00 1 2 DLI 5: Implementation of Quality and Climate Standards for Healthcare Facilities 40.00 3 4 Page 34 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Results Area 4: Improved efficiency through coordination and integration of health subsystems. DLI 6: Savings in the purchase of essential medicines 39.25 2 4 DLI 7: Argentina Integrated Health Services Plan (PAISS) 21.00 2 4 DLI 8: Administrative Act for Digital Prescription 10.00 1 4 DLI 9: Adaptation and mitigation strategies for climate change 33.00 2 4 62 Total: 299.25 17 58. Verification arrangements. Independent verification of achievement of the DLIs will be done by the National Internal Audit Agency (SIGEN). SIGEN is the Internal Auditing Agency of the Federal Government, under the authority of the President. To promote the use of the country system, SIGEN has been proposed for the verification of DLIs. At the same time, implementing the verification function under this PforR is expected to further strengthen SIGEN’s capacities, contributing to institutional development for evaluation in the sector. 59. Distinct types of DLRs will require different verification methodologies. First, DLRs reflecting processes, such as development and approval of norms and plans, will require desk-based verification. Second, DLRs reflecting effective coverage (DLI 2) and delivery capacity, effective utilization and registration , such as DLI 3 (MMR vaccination) and DLI 4 (breast cancer timely treatment, among others, will be reported through existing government information systems, particularly the Sumar databases, the NOMIVAC, the SITAM, the RITA, and the Federal Registry of Health Facilities (REFES), all included under the MSN’s health management and information system (HMIS); the Health Integrated Information System (SISA). Using a standard data quality audit methodology, verification will examine the robustness of the reporting system. Reporting and verification arrangements, processes, protocols, and methodologies, acceptable to the Bank, will be documented in the Program Operations Manual (POM). III. PROGRAM IMPLEMENTATION A. Institutional and Implementation Arrangements 60. The Program will be implemented by the MSN which will provide overall oversight of Program execution. The MSN will be responsible for high level coordination with the other actors involved in Program implementation. The MSN is responsible for the overall management of the health system; and develops norms, standards and guidelines and provides technical assistance for their implementation. (Table A3.3 includes the roles and responsibilities of each entity under the MSN and Provinces to achieve each DLR). 61. The National Secretariat of Equity in Health (SES) within the MSN will be the technical and operational coordination unit for the Program. The National Directorate of Provincial Systems Strengthening (DNFSP) under the SES will be responsible for coordinating the Program activities through the MSN’s different Secretariats such as Quality, and Service Delivery, and its Directorates and the INC. To this end, the DNFSP will be responsible for coordinating the collection of data to monitor indicator performance and DLIs. DNFSP is staffed with a National Director who will be the Program Coordinator, and with technical staff members who have adequate capacity to support the Program implementation. Implementation of the PforR will also build on the successful implementation arrangements under the Sumar and Proteger programs previously supported by the Bank, as the 62 The Loan Front-end Fee of US$750,000 will be taken from DLI 6, reducing the total amount to be disbursed to US$299.25 million. Page 35 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Project Coordination Team (PCT) that was established within the MSN for the purpose of supporting the Sumar and Proteger programs has been further institutionalized. 62. The Secretariat of Administrative Management (SGA) within the MSN, will be responsible for budget management, procurement, and financial management, all this in accordance with Decree 945/2017 articles 1 and 2. Specifically, the General Directorate of Projects with External Financing (DGPFE), under the SGA, will oversee reporting on the financial statements, Program Action Plan, DLIs, and will coordinate with the external verification agency for submitting the disbursement requests to the Bank. 63. Within the MSN Program‐relevant departments, as well as in each of the other participating entities, a team of one or two key staff members will be designated as focal points. They will be responsible for supervising Program implementation according to their areas of competence and ensuring timely coordination to achieve the DLRs’ targets. They will work in close collaboration with DNFSP. 64. The provinces are responsible for the provision of healthcare to the Program’s beneficiaries. Participation by provinces will be governed by the corresponding section of the Participation Agreement pertaining to the Program, signed between each province (represented by the Minister of Health) and the MSN, to cover the duration of the Program period. These agreements will cover the requirements related to the Program including, inter alia, the technical, financial, administrative, fiduciary, and environmental and social aspects of provincial participation in the Program. These agreements are linked with DLR 1.3 and will be needed for transferring funds under the PforR result framework to the participating province. 65. The Government Supreme Auditing Institution (AGN) will be responsible for conducting annual financial audits of the MSN; covering the Program transfers made by the MSN to participating provinces. 66. The SIGEN, through a dedicated team at the central level, will be responsible for the verification of DLIs, according to Terms of Reference for the Verification Agency acceptable to the Bank and to be included in the POM. Specialized staff managed by SIGEN’s central level and separated from the Internal Audit Unit at the MSN will perform tasks and validations required for DLIs verification specified in the Terms of Reference, agreed with the Bank. SIGEN has the capacity to provide independent verification for the DLIs and to ensure credible verification of the achievement of the DLRs. B. Results Monitoring and Evaluation 67. The results framework indicators are measured by the DLIs and the intermediate results indicators (IRI) and will rely on well-developed government monitoring and reporting systems. The DLIs will be monitored and verified on existing HMIS at MSN, SISA. The progress of process indicators related to regulatory changes or institutional process will be verified as published in the Country Official Bulletin and in the Electronic Document Management and in e-SIDIF. Data for access to health services will be built on proven robust information systems and instruments that are key for the result-based capitation payments of Sumar Program, all under the MSN’s HMIS (the SISA) and or any other replaced system, including, inter alia: (i) the Roster Management System (Sistema de Gestión de Padrones); (ii) Provincial Health Service Billing Systems; (iii) Health Service Consumption Registries and Medical Records; and (iv) the Tracer System; (v) the SITAM and the RITA, managed by the INC (both systems will be further strengthened during implementation of the Program; (vi) the NOMIVAC that records vaccinations at the individual level; (vii) the Federal Registry of Health Facilities (REFES) and Research Electronic Data Capture (Redcap). Indicators related to effective access and utilization of key health services will be Page 36 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) disaggregated by sex. The result framework indicators will be measured on the same HMIS and will be monitored periodically. 68. The MSN’s SES, through the DNFSP, will be responsible for collecting the information required to ensure DLI compliance and for submitting it to DGPFE for SIGEN’s verification. Also, the DNFSP will ensure that technical and analytical areas of the MSN, and the MSPs, report timely progress of result framework indicators, and serve as focal point to the World Bank Group for purpose of program technical supervision. 69. Important to highlight is that all records containing personal data are stored in ARSAT’s national data center, a publicly owned company. The World Bank, through the Argentina: Strengthening Data Infrastructure to Close the Digital Gap Project (P178609) Project and the Digital Inclusion and Innovation in Public Services Project (P174946), carried out assessments63 to ensure that ARSAT implements the appropriate cybersecurity standards and complies with international regulations. The high standards ensure the correct preservation of the data stored and the operation of its infrastructure. In addition, personal data privacy is regulated by laws 26,529 and 25,326. Law 25,326, the Personal Data Protection Law, also follows international standards and has been considered as granting adequate protection by the European Commission. Decree 1558 of 2001 includes regulations issued under the Personal Data Protection Law. C. Disbursement Arrangements 70. Disbursement of Bank loan proceeds will be made at the request of the Borrower upon achievement of DLRs. Some DLRs (see DLR matrix – Annex 2) are scalable, thus allowing for disbursements to be proportional to the progress towards achieving the targeted DLR value. Other DLRs are not scalable, as the indicators relate to actions that are either achieved or not. Some DLRs are time-bound, to be reported and verified annually, while other DLRs are not time-bound, to be achieved anytime during the PforR implementation period; funds not disbursed in one year will be available for disbursement in subsequent years. 71. Five DLRs (DLRs 1.1, 1.4, 5.3, 8.1 & 9.1) are expected to be achieved prior to effectiveness, amounting to US$50 million (17 percent of the Loan amount). In addition, advances of up to a cumulative 30 percent of the amount allocated to the DLIs under the Program (as a combination of the prior results and the advances) will be disbursed upon request of the Government after effectiveness (in this case US$40 million; 13 percent of the Loan amount). The advance is necessary for implementation of activities to achieve DLRs in the initial stage. The advance will be deducted from disbursements against achievement of DLRs and will be available again on a rolling basis if required. 72. The SGA will prepare technical reports to document the status of achievement of DLRs. The technical reports will be verified by the SIGEN as the selected verification agency. Upon the validation of DLRs by the SIGEN, the SGA will notify the achievement of DLRs and corresponding DLR values to the Bank, supported by the relevant evidence and documentation. Following the Bank's review of the complete documentation, including any additional information considered necessary to confirm the achievement of the DLR, the Bank will confirm the achievement and the level of Program financing proceeds available for disbursement against each DLR. 73. Disbursement requests (Withdrawal Applications) will be submitted to the Bank by the MSN using the Bank’s e-disbursement system (Client Connection). A copy of the Bank’s official communication, confirming the 63 Assesments were carried out at Projects’ appraisal; November 2022 and March 2021, respectively. Page 37 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLR achievement, should be attached to the disbursement requests. MSN will copy the Ministry of Economy in the entire verification and disbursement processes. 74. Funds will be disbursed from the Bank to the MSN in US dollars based on the achieved DLRs. An amount of US$50 million of the PforR operation will be disbursed on account of the DLRs met between the date of the Program Concept Review and the date of the Legal Agreement (Prior Results). 75. As mentioned above, advances will be available under this operation. In this regard, the Bank may make an advance payment of up to US$40 million of the Program funds for one or more DLRs which still need to be achieved. Proceeds of the advance will be disbursed to an MSN account in the Banco de la Nación Argentina (BNA) denominated in US dollars. When DLRs are achieved, the amount of the advance is recovered from the amount due to be disbursed under such DLRs. The advanced amount recovered by the Bank is then available for additional advances (“revolving advance”). When an advance has been provided and the DLRs are achieved and verified, the advance is always recovered first. If the amount allocated to a DLR that has been achieved and verified is larger than the advance, then the Bank will disburse the amount in excess of the advance through a Reimbursement (DLR Payment). 76. The operational arrangement for the transfer of resources will be described in detail in the POM, to be approved at effectiveness. D. Capacity Building 77. The Program implementation will build on existing processes developed under previous World Bank- financed Investment Project Financing operations, while strengthening the government’s technical areas to fully be in charge of carrying them out without the regular Bank review support. The proposed PforR builds on the extensive engagement of the World Bank in the health sector in Argentina over the last 17 years, comprising both lending and technical assistance. In particular, the Program will build on the design and lessons learned from the implementation of the Sumar Program (and its predecessors) and the Proteger Program. Both programs implemented results-based financing mechanisms from the MSN to the provinces and health providers. The support of the World Bank will help ensure that important national and international lessons about the implementation of these mechanisms are reflected in the design and implementation of the Program that fully relies on national systems. The PforR will support the development of the needed capacities to institutionalize these processes, which includes a close follow up from a national team to the provinces and developing champions at the MSP to transition from the World Bank result-based processes and systems to the national systems. Based on the experience of having supported previous project implementation, the World Bank team will provide technical assistance to the MSN in this important step. The Program Action Plan includes commitments regarding the strengthening of the MSN purchasing function. 78. As part of technical assessment, the following areas have been identified for technical assistance, capacity building, and institutional strengthening: (i) strengthening results-based financing mechanisms and their institutionalization based on global experience (already ongoing as part of PforR preparation); (ii) calculating and verifying result-based financial transfers to provinces; (iii) reviewing the drug list for centralized procurement (based on criteria from evidence-based medicine, health technology assessment, and budget impact analysis) as well as the procurement methodology; (iv) strengthening and formalizing a high complexity healthcare network; and (v) building capacity on health system strengthening focused on the integration of the health system. Page 38 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Depending on the nature of the task, capacity-building activities can take the form of just-in-time technical assistance, knowledge and experience exchange with other countries, or long-term advisory support. 79. As part of the fiduciary systems assessment, the following areas have been identified for capacity building and institutional strengthening: (i) the Borrower’s unfamiliarity with the PforR Instrument; and (ii) delays in implementation arising from the time to prepare technical specifications and conduct technical evaluation as well as delays in obtaining the permissions to import and pay for them that could affect the procurement of specific goods. 80. The implementation of the Program Action Plan will also contribute to the development of systems and capacities in the areas of Environmental and Social management and fiduciary management. The Program Action Plan (Annex 6) includes the development and implementation of a policy framework for environmental and social management capacity development and for financial management. IV. ASSESSMENT SUMMARY A. Technical (including program economic evaluation) Strategic Relevance and Technical Soundness of the Program 81. The strategic lines and activities of the Government program (NIHP) to be supported under the PforR have been purposefully chosen, drawing on the extensive analytical work and technical assistance provided by the World Bank through its health sector engagement, and designed following evidence-based interventions. For RA1, the institutionalization of cost-effective results-based transfers from the federal level to the provinces and to service providers paired with robust quality-control mechanisms as well as the design of mechanisms to create a national fund for high-complexity diseases;64 for RA2, the enrollment of the otherwise uninsured population in a program that can provide them with effective health coverage based on the utilization of essential health services from an explicit benefits package provided according to established quality protocols; for RA3, strategies to improve the integration and quality of care developed in the PAISS, the National Strategy for Quality,65 and the formalization of an integrated pediatric oncology network; and for RA4, methodologies to inform funding choices of health technology (through a national benefits package) and to improve centralized procurement as well as measures to digitize prescriptions and advance the sector’s capacity to mitigate and adapt to climate change. In several key aspects, the NIHP directly builds on the findings and recommendations of 17 years of World Bank-financed project implementation (see Annex 3 for the Technical Assessment). 64 Some of the evaluations documenting the positive impacts include: (i) quasi-experimental impact evaluation of the Plan Nacer, Gertler P., Giovagnoli P., and Martinez S., (2014). Rewarding Performance to Enable a Healthy Start: The Impact of Plan Nacer on Birth Outcomes of Babies Born into Poverty. Policy Research Working Paper 6,884, World Bank. (http://documents.worldbank.org/curated/en/910221468002421288/pdf/WPS6884.pdf); (ii) 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 21,361; (ii) Generation of evidence of the results, documentation of lessons learned and good practices. See, for example, Sumar (2015), 5 años de implementación del Programa Nacional de Cardiopatías Congénitas, NHM, Bs. As. (http://iah.salud.gob.ar/doc/Documento145.pdf) 65 National Strategy for Quality established by MSN Resolution 2546/2021; https://www.boletinoficial.gob.ar/detalleAviso/primera/249893/20210922 Page 39 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 82. The RAs of the PforR are aligned with the “iron triangle” of healthcare which summarizes the interdependent relationship between three key intermediate objectives of healthcare systems: efficiency (directly related to costs), quality, and coverage (which is partially determined by access). This triangle represents the idea that it is difficult to achieve all three of these elements simultaneously. Cost or efficiency refers to the financial burden associated with healthcare services (including the cost of medical procedures, medications, and insurance) and the need to minimize the resources needed to produce such healthcare services. Quality refers to the level of care that patients receive, including the accuracy of diagnoses, the effectiveness of treatments, and the overall experience. For coverage, the availability and affordability of healthcare services is a precondition, including the availability of medical providers and insurance coverage. Simultaneously balancing the three elements (i.e., bending the healthcare cost curve, increasing health coverage and advancing quality of care) is a complex yet necessary and continuous challenge for policymakers, healthcare providers, and other stakeholders. Expenditure Framework 83. The Government program (NIHP) has a total projected budget of US$920 million for 2023, and an estimated total budget of US$3,072 million for the period 2023-2025. Within the NIHP, 10 budget programs and 14 activities were prioritized to be supported by the PforR’s expenditure framework, based on their scope and volume of resources (see Table A3.4 in Annex 3). These prioritized programs will not be co-financed by other multilateral development institutions, but by national funds. The total resources for the expenditure framework are US$1,713 million for the period 2023-2025, representing 56 percent of total NIHP. Considering the estimation for 2023, the budget is US$417 million, which accounts for 45 percent of total 2023 budget of the NIHP. The selected budget lines to be supported by the PforR correspond to programs and activities that both have been supported by the Bank during many years, as well as those that have historically had high levels of execution so that the flow of funds will be guaranteed. 84. The budget lines in the expenditure framework include the different expenditure categories (human resources, consumption goods, services, equipment, and transfers) for the period 2023-2025 (see Table A3.5 in Annex 3). Expenditures associated with infrastructure are not included in the scope of the expenditure framework. 85. The NIHP to be supported by the PforR is aligned with the RAs and represents an adequate portion of the total assigned budget. Furthermore, the programs and activities included correspond to core functions of the MSN and have been historically well executed by the MSN. The average MSN budget execution rate from 2014- 2021 was 95.9 percent (see Figure A3.4 in the annex for more detail) . Additionally, the main budget lines included in the expenditure framework have also had high execution rates. The Vaccination program and Essential Drugs program had an average budget execution rate of 97.9 percent and 93.2 percent, respectively. The transfers to provinces have had high levels of budget execution over almost two decades mainly related to the funds transferred through the Sumar Program, which had an average budget execution rate of 93.7 percent from 2014 to 2021. These figures are evidence that the supported program budget lines have been well executed and that their financing is sustainable. Economic justification 86. The economic benefits of the Program are estimated by assessing the monetarized or economic value of the expected reductions in the burden of disease attributable to the interventions supported by the Program as well as direct cost savings from improved pharmaceutical procurement. The Program will provide support to Page 40 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) a set of strategic lines that the MSN has previously been implementing through the Sumar and Proteger programs and that are anchored in the PAISS and the National Quality Plan. It is expected that these interventions will continue to generate significant positive impacts in terms of the health outcomes of the target population and the quality and efficiency of healthcare services. The costs of Program implementation occur in the first four years of the analysis (according to investments in the Program and disbursements from the PforR), whereas the long-term benefits accrue over a period of ten years. The economic analysis includes the calculation of the Internal Rate of Return (IRR) and the Net Present Value, considering a discount rate of four percent under the baseline scenario. A sensitivity analysis is also performed to determine the variation in the IRR of the investments if any of the high- impact factors were to change. The benefits deriving from Program interventions are estimated using the impact on population health status as measured in terms of disability-adjusted life years (DALYs). The direct benefits of the Program are calculated by using forward projections of disability-adjusted life years (DALYs) averted (that is, healthy life years gained) over the 10-year period from 2023 to 2032 due to improvements in access to quality healthcare services (vis-à-vis a counterfactual in which the Program is not being implemented). The second benefit comes from the cost savings from centralized purchasing of high-priced drugs. The methodology applied for this economic analysis builds on the ones previously developed for the World Bank- financed projects in support of the Sumar and Proteger Programs. In all considered scenarios, the Program is economically profitable, as attested by the net present value and IRR. Table 9. Summary of the Cost-Benefit Analysis Baseline Low-Impact High-Impact Scenario Scenario Scenario Net present value (in US$ million) 265.4 196.6 370.7 Internal rate of return 31.6% 24.4% 42.9% Source: World Bank estimates B. Fiduciary66 87. The Procurement and Financial Management systems’ capacity and performance, with the implementation of the proposed mitigating measures and agreed actions to strengthen the systems (which are reflected in the fiduciary systems assessment), are adequate to provide reasonable assurance that Program funds will be used for the intended purposes, with due attention to the principles of economy, efficiency, effectiveness, transparency, and accountability. 88. Financial Management. According to the 2019 Argentina Public Expenditure and Financial Accountability Assessment (PEFA),67 Argentina’s national Public Financial Management Systems align reasonably well with international standards and good practices. The assessment showed advanced performance in the “transparency of public finances” dimension and solid performance in the “policy-based fiscal strategy and budgeting” pillar. However, the “management of assets and liabilities” and “predictability and control in budget execution” pillars 66 The fiduciary systems assessment will be aligned and informed by the previous assessments done under recently approved PforRs in Argentina; P172689 Buenos Aires Water Supply and Sanitation with a Focus on Vulnerable Areas Program, approved on February 25,2021 and P168911 Improving Inclusion in Secondary and Higher Education, approved on June 28, 2019 67 Argentina - Public Expenditure and Financial Accountability (PEFA): Performance Assessment Report, Report AUS0001244, December 2019: https://documentsinternal.worldbank.org/Search/32030813 Page 41 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) had mixed results. Additionally, the “external scrutiny and audit” pillar indicators fell below good international practices. Although the systems and tools in place are adequate for supporting fiscal and budgetary outcomes, there is still room for improving the efficiency and effectiveness of public resources. 89. The National Public Sector Financial Management and Control Systems Act68 is the foundation of Argentina’s public financial management system. It establishes the legal basis for budgeting, public credit, treasury, government accounting, and internal control functions and systems. The Supplementary and Permanent Budget Act outlines the annual budgeting process, which begins with the Executive branch setting priorities and policies for the following year, estimating revenue and expenditure. The budget proposal is submitted to the Legislature by September 15 for discussion, adjustment, and approval. Once approved, the annual budget law is published in the official gazette (boletín oficial) and on the Ministry of Economy’s website. Monthly budget execution reports are available on the Ministry’s website, with annual reports prepared as part of the Central Government’s financial statements. 90. Institutional arrangements for the Program. MSN through its SGA is expected to hold the fiduciary responsibilities to manage the Program. The SGA is comprised of five General Directorates, including the DGPFE which is currently in charge of fiduciary responsibilities of other World Bank Investment Project Financing (IPF) operations69 but without previous experience on PforR instruments. A detailed fiduciary systems assessment covering all institutions involved in implementing expenditures has been prepared. Key Financial Management and Procurement action items have been identified as development activities or risk mitigation measures and have been included in the Program Action Plan. 91. Anticorruption guidelines. To enforce the World Bank’s Anticorruption Guidelines70 (ACGs) for PforR operations, MSN will promptly notify the Bank of any fraud or corruption complaints against MSN. MSN must provide the Bank with all requested records and information regarding such matters. If necessary, the Bank may request that the Government and/or MSN use their legal rights and remedies to obtain additional information for an investigation. However, the Bank retains the right to request information directly from recipients of Bank financing. The Government and the MSN must ensure that these recipients are aware of this possibility. Failure to provide requested documentation may result in the disqualification of expenditures for Bank financing. If a sanctionable offense is found, the Bank may pursue sanctions in accordance with its procedures. The external auditors will confirm ex post that contracts are not awarded to debarred or suspended parties. MSN will report any allegations of fraud or corruption to the Bank twice a year. The Program Action Plan recommends certain actions to manage fiduciary responsibilities for the Program. 92. Procurement. Procurement will be centrally implemented by MSN at the national level and no procurement is expected at the provincial level. For the implementation of procurement activities, MSN will follow the procedures of: (i) national legislation regulated by a central regulatory unit (ONC): and (ii) special regimes based on technical cooperation agreements approved by the National Congress, particularly with the Pan American Health Organization (PAHO) and United Nations Development Programme (UNDP). The Borrower has 68 The National Public Sector Financial Management and Control Systems Act, issued in 1992 with subsequent revisions: http://servicios.infoleg.gob.ar/infolegInternet/anexos/0-4999/554/texact.htm 69 P163345- Supporting Effective UHC in Argentina, partially financed by the Loan 8853-AR and its additional financing Loan 9222-AR, amounting to US$300 and US$250 million, respectively, with closing date on December 31, 2023; and P173767-AR: COVID-19 Emergency Response Project, partially financed by the Loan 9083-AR and its additional financing Loan 9292-AR, amounting to US$35 million and US$500 million, respectively, with closing date on April 30, 2024. 70Dated February 1, 2012, and revised July 10, 2015. Page 42 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) shared the legal framework and past performance of similar activities to inform the fiduciary systems assessment and provide a basis of analysis to assess whether there are enough elements to conclude that the Program will be used for the established objectives, with due attention to the World Bank’s procurement principles. Based on this, the assessment has identified specific risks and the associated mitigation measure to address it. The main conclusions of the assessment indicate that: (i) MSN has extensive experience implementing the type of procurement that the Program includes; (ii) the mandatory use of the national e-procurement system (COMPR.AR) and the electronic management system (GDE) to handle procurement activities supports traceability, efficiency and transparency of the processes; (iii) although the national legislation already includes a provision that forbids awarding to firms ineligible for multilateral development institutions, there is a potential risk of omission in verifying this condition before awarding the contract. This risk would be mitigated through the request to include in the POM a verification of this condition by the MSN prior to contract award. In addition the external audit will confirm that the firm eligibility verification had been done; (iv) there is a risk for potential delays in implementation arising from the time to prepare technical specifications and conduct technical evaluation as well as delays in obtaining the permissions to import and pay for them that could affect the procurement of specific goods; (v) as the national legislation does not count with standards for determining qualification criteria, there is a risk of using restrictive requirements on bidding documents that will be addressed in the POM to promote open competition; (vi) there are opportunities to improve efficiency through consolidation of procurable items; and (vii) the POM will include a requirement to apply competitive methods as the default approach whenever applicable following the national legislation and UNDP framework. 93. There are no potential high-value contracts identified under the Program. The proposed Program is not expected to finance any contract at or above prevailing Operations Procurement Review Committee (OPRC) thresholds. C. Environmental and Social 94. The World Bank carried out an Environment and Social Systems Assessment (ESSA) from January 2023- April 202371 for PforR Financing. The 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 governmental environmental and social policies, legislation, program procedures and institutional systems are consistent with the core principles of the World Bank policies. Finally, the ESSA includes recommendations and Program Action Plans to address the identified gaps and to enhance performance during Program implementation. Based on the definition of PforR boundaries, the proposed PforR will support four out of five domains of the NIHP 2023-2028 over the three-year period of 2023-2025 as defined under the PforR Boundary above. The Program is not expected to contain activities that should be excluded from PforR as established in the World Bank Policy. 95. For the ESSA, the World Bank team reviewed the environmental and social systems that are relevant to the Program. The ESSA concluded that the risk is Moderate for both environmental and social risks. The environmental risks of the Program are linked to the management of healthcare waste and electronic waste, 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 World Bank team also addressed the coordination of public policies with the spatial distribution of the population in the 71 The draft assessment was published on April 5, 2023. Page 43 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) territory associated with natural environments and the capacity of the health establishments that implement the accompanying route to prepare, face, and adapt to the impacts of natural disasters, economic crises, pandemics, and climate change. The ESSA found access gaps to healthcare 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 includes 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 healthcare waste and electronic waste were also identified, which are addressed with Program Action Plan actions and recommendations. Virtual consultations were conducted on April 10, 13 and 18, 2023 with key health stakeholders and representatives of vulnerable groups, including indigenous peoples, as part of the preparation of the ESSA. The draft ESSA has been available on the World Bank website for public consultation since March 31 and comments by email were also received until April 21, 2023. The final version of the ESSA includes comments received during the consultation process and will be disclosed on the World Bank’s website and on the MSN website by June 9, 2023. 96. Grievance Redress. Communities and individuals who believe that they are adversely affected as a result of a Bank supported PforR operation, as defined by the applicable policy and procedures, may submit complaints to the existing program grievance mechanism or the Bank’s Grievance Redress Service (GRS). The Grievance Redress Service ensures that complaints received are promptly reviewed to address pertinent concerns. Project affected communities and individuals may submit their complaint to the Bank’s independent Accountabil ity Mechanism (AM). The Accountability Mechanism houses the Inspection Panel, which determines whether harm occurred, or could occur, as a result of Bank non-compliance with its policies and procedures, and the Dispute Resolution Service, which provides communities and borrowers with the opportunity to address complaints through dispute resolution. Complaints may be submitted at any time after concerns have been brought directly to the Bank’s attention, and Bank Management has been given an opportunity to respond. For information on how to submit complaints to the Bank’s Grievance Redress Service, please visit http://www.worldbank.org/GRS. For information on how to submit complaints to the Bank’s Accountability Mechanism, please visit https://accountability.worldbank.org. D. Gender 97. The PforR has a strong focus towards increased gender equality and in closing gender gaps in the provision of social and health services. The Program is expected to generate substantial social and health benefits, particularly through its efforts to improve quality and efficiency in the provision of health services for: (i) victims of GBV; and (ii) breast cancer. Argentina has made several specific commitments advancing gender equality, including to continue to promote initiatives to end all forms of discrimination against women and girls, and GBV. Among others, the Micaela Law in 2019 established mandatory training in combating GBV for all public officials in the executive, legislative, and judicial branches. Building on this platform, the country’s Ministry of Women, Gender and Diversity developed the Program for a Comprehensive Approach to Tackle GBV. The Program seeks to establish common guidelines and responses for addressing the challenge. 98. GBV has immediate effects on health, which in some cases, is fatal. In the WHO multi-country study on women’s health and domestic violence, between 19 and 55 percent of women who had ever experienced physical Page 44 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) violence by their intimate partner reported being acutely physically injured as a result.72 Physical, mental, and behavioral health consequences can also persist long after the violence has stopped. Evidence links physical and sexual violence during pregnancy to complications, including low maternal weight gain, miscarriage, and stillbirth. Both physical and sexual violence have been linked to a greater risk of adverse mental health outcomes among women. Depression and post-traumatic stress disorder, which have substantial comorbidity, are the most prevalent mental-health sequelae of intimate-partner violence.73 In Argentina, almost 30 percent of women that have experienced intimate-partner violence by a former partner and 10 percent of those who have experienced it by a current partner reported a lack of desire to continue living.74 99. At the health system level, analyses of the relations between partner abuse, health status, and use of medical care in women in population-based and clinical studies have shown poorer overall health. Data examining support seeking behaviors note that only 41.5 percent women suffering from GBV turned to people they knew for support. In the case of physical abuse, 60 percent sought help or counselling. Around 40-60 percent experience their situation in solitude without any kind of support. Furthermore, according to WHO, women who experience intimate-partner violence are less likely to seek preventive care. This has clear implications for the overall health of women who experience violence, and for health-care costs, since prevention is usually more cost effective than treatment. 100. The Government’s NIHP includes one Strategic Line for effective coverage of health services for women from a gender perspective. In 2020, the MSN created the National Plan for Gender and Diversity in Public Health Policies (MSN Resolution 1886/2020) to implement a gender and diversity perspective in the MSN and healthcare facilities in all the country. The PforR will support actions of the Plan related to: (i) training health personnel in gender and diversity at all levels: particularly in relation to the new clinical manual “Comprehensive healthcare in situations of GBV. Tools for health teams” developed by the MSN, with the coordination of the Directorate of Gender and Diversity, targetting interdisciplinary health teams, especially people who work at the first level of care. Its purpose is to provide them with tools for the comprehensive care of people who are going through or have gone through situations of GBV. (ii) designing and implementing a clinical guideline and routes for identifying and providing general care to persons subjected to GBV. (iii) technical assistance to provinces for implementing a gender and diversity perspective in primary healthcare services: communication and prior coordination between the services that make up the protection circuit is essential to ensure comprehensive care and to avoid the revictimization of people in a situation of GBV. Within the scope of this program there will be support for the creation of local specialized care teams dedicated to the follow-up of GBV cases and coordination with other actors, strengthening the intersectoral approach networks. (iv) the production of graphic and audiovisual material for the dissemination of GBV-related resources. 72 García-Moreno, Claudia; Jansen, Henrica; Ellsberg, Mary; Heise, Lori; Watts, Charlotte. (2005). WHO Multi Country Study on Women's Health and Domestic Violence Against Women. https://apps.who.int/iris/handle/10665/43309 73 https://www.thelancet.com/action/showPdf?pii=S0140-6736%2802%2908336-8 74 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 Page 45 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 101. Two IRIs will monitor progress in this area: (i) the Program will track the GBV survivor population with public health coverage of healthcare services provided for GBV (number of people registered under the benefit linked to the care for victims of GBV; and (ii) number of provinces with georeferenced orientation teams to recognize, medically manage, and refer GBV victims to appropriate services, in at least five percent of the province health facilities (the team is formed; the tools are provided, and then it is assembled and georeferenced by the MSN so that survivors can also know where to get support). 102. As for breast cancer, improving breast cancer health outcomes has long been a key public health priority for Argentina. Breast cancer is the first cause of death by tumors in women and the COVID-19 pandemic has unfortunately erased some of the universal health coverage gains on screening brought through Sumar. Furthermore, the prolonged economic crisis has intensified the pressure on the Argentine public sector and thus in the population that exclusively relies on the public sector without any social security coverage. For example, in Buenos Aires Province, the percentage of women aged 50-70 receiving a mammogram is higher among those with social security coverage (53 percent) than those from the public health delivery network (29.5 percent). 103. Reducing gender gaps in cancer coverage and outcomes are reflected in the Program’s activities related with the early detection and timely treatment of breast cancer. The Program will contribute to addressing some of the barriers for breast cancer screening and early diagnosis. On the one hand, the Program will monitor improvements in breast cancer screening coverage, especially given the drops observed during the pandemic (see the IRI). As mentioned previously, access to mammograms with high quality standards is also a barrier for the diagnosis of breast cancer. To ensure that the quality of these services is also improved, actions will be taken to certify (quality assurance) Mammography Centers in accordance with the 2020 Manual for the evaluation of quality and safety standards in breast diagnostic services published by the INC (see the IRI). Once diagnosed, the care of people with cancer requires moving from a reactive model, centered on the disease, to a proactive and planned model, centered on the person and their context. Improvements in the coordination75 and continuity76 of care is critical. According to the Provincial of Buenos Aires Cancer Institute, women with breast cancer with exclusive public coverage living in the Province wait, on average, 31 days to receive treatment medication.77 The Program will support, through the result-based capitation (RA2) and the actions under quality coordination (RA3), improvements in the earlier diagnosis and treatment. The Program development result will be measured by a PDI tracking the percentage of women with diagnosed breast cancer that receives timely treatment and is registered in MSN systems, this will also be tracked and generate disbursements under DLI 4. Finally timely access to oncologic medicines, including those for women with breast cancer, will be supported under RA3, mainly related to digitalized stock control for oncological medicines, and the administrative act for digital prescription. 104. This is complemented by activities within the preparation of a new Project (Strengthening the Digital Health Agenda Project, P179534) in the Province of Buenos Aires, as it will support the strengthening of clinical information system – one of the pillars for continuity and coordination of services. Overall, continuity of care will be tracked through one of the PDIs: “Percentage of women aged 30-74 with diagnosed breast cancer that receives timely treatment”. 75 Coordination of care requires a health information system that contains all the information related to the health of individuals and that can contribute to their care network. 76 Continuity of care is achieved by the degree to which individuals and primary health centers mutually agree on the care required by the former and the latter are able to provide it at any point in the healthcare network. 77 Medication prescription for breast cancer refers to those treatment medicines included in the VADEMECUM approved and financed by the Provincial Cancer Institute. Page 46 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) E. Climate Change 105. As mentioned in the Country and Sector Context, Argentina ranks amongst the ten emerging economies most vulnerable to climate change. Average annual temperatures are expected to increase by 1.5°C by mid- century and country-wide annual average precipitation is expected to increase with wide geographic variation throughout the country. 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. From 2000 to 2011, flooding events affected 5.5 million people. 106. Climate change is posing additional threats to the ability of the health system to provide access and continuity of care and its effects are already noticeable, in the form of increased cases and risks of flash or surface flooding, heatwave events, and wind gusts accompanied by precipitation. As mentioned in the Sectoral Context above, the extreme weather events, including heatwaves, floods, and droughts are expected to increase in frequency and severity, which in turn leads to increasing damages to healthcare facilities, sometimes disabling them completely. Rising temperatures will expand the range, seasonality, and distribution of vector-borne illnesses such as dengue. Populations living around irrigated areas are nearly six times more at risk. Heat discomfort and heat stress increases mortality and morbidity for the most underserved, especially the elderly, children, and pregnant women. 107. The PforR supports adaptation to climate change through investments in primary healthcare facilities and services (see Table 10). Table 10. Climate Adaptation and Mitigation Measures in the Program Climate Co-Benefits DLR / DLI Description Financing Amount DLR 5.1 (US$5 million): 24% CCB Quality Improvements for primary healthcares including 22 (out of Administrative act of 22 out of 92 measures 92) measures assessing implementation of climate adaptation actions creation of the Quality including surveillance of conditions that are climate sensitive in Tool for primary Argentina and development of health facility emergency healthcare which includes preparedness and response plans. This will help primary health Climate standards. facilities and services adapt to the impacts of climate change. DLR 5.2 (US$25 million): 44% CCB Quality Improvements for Secondary Level Health Facilities including Inpatient public health 26 out of 59 measures 26 (out of 56) measures assessing implementation of climate facilities certified as adaptation actions including ensuring climate emergency facilities committed to preparedness and response measures are in place; the presence of quality which includes climate emergency preparedness and response plans; and ensuring climate standards high quality treatment of climate sensitive conditions. This will help according to MSN primary health facilities and services adapt to the impacts of climate Resolution 1744/21. change. DLI 9 (US$33 million): 100% CCB This DLI supports the development of actions to implement the Adaptation and mitigation National Climate Change Adaptation and Mitigation Plan through: (i) strategies for climate an administrative act approving the health and climate change change (US$33 million) strategy, which will support the development of the strategy to operationalize the plan (DLR 9.1); and (ii) approval of provincial climate change plans through administrative acts by MSP (DLR 9.2). Page 47 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) V. RISKS 108. The overall risk rating for the Program is Substantial. Risks related to: (i) political and governance; (ii) macroeconomic context; (iii) sector strategies and policies; (iv) institutional capacity for implementation; and fiduciary risks are rated Substantial. 109. The political and governance risks are Substantial. The upcoming national elections in October 2023, jointly with elections throughout 2023 and 2024 for most provinces, could bring changes at different levels of the administration that could jeopardize the current government health strategy supported through this operation. In this case, the likely impact would be that the speed of implementation may be slower than originally envisioned or that the overall impact may be less than originally expected. A mitigating factor is that the devastating consequences of the COVID-19 pandemic has created an enhanced political awareness about the importance of having a strong and resilient health sector as a basic condition for economic growth and development. In addition, it has shown the benefits of an integrated health system working in a coordinated manner and efficiently using the scarce resources available to respond to the unprecedent increase in health service demand at the peak of outbreak. In addition, the PforR’s RAs will support actions drawn on the extensive World Bank engagement in the health sector in Argentina over the past decade, including buy-in from different government administrations. Furthermore, these risks will be partially mitigated through a strong commitment from the national authorities to expedite as much as possible the internal administrative procedures to authorize the signing of the Loan Agreement prior to elections and to proactively engage with key sector stakeholders to ensure strong buy-in throughout the implementation period. 110. The macroeconomic risks are Substantial. Significant macroeconomic imbalances persist, evidenced by fiscal dominance, high inflation, pressures on the exchange rate and high-country risk. Against this background, deteriorating growth prospects will reduce national fiscal revenues and the sovereign fiscal consolidation needs may lead to a reduction of the current and expected budget allocated to the health sector, including transfers to the provinces which are one of the key activities supported through this operation. Both events will limit the ability to implement the Program, putting at risk the achievement of results that trigger disbursements and the accomplishment of PDO. Additionally, exchange rate management policies may trigger additional import controls, delays in obtaining the permissions to import and pay for them that could affect the procurement of specific goods (medical equipment and supplies, medicines, and Information and Technology goods) that might be required to implement the Program. To address this risk, the Ministry of Economy, the MSN and the World Bank teams will do a bi-annual monitoring of the Program’s Financial Statements and Program Expenditure Framework execution to timely assess the potential impact and propose mitigation measures to address it. 111. The sectoral risk is rated as Substantial. Due to the fragmented nature of the Argentine health system, the implementation of the proposed Program will require support from the provinces since they are responsible for health service provision within their territory. Limited provincial support could negatively affect the implementation of key activities, the accomplishment of DLIs and the achievement of PDOs. The MSN is currently preparing a transition strategy from the ongoing Programs to the implementation of the PforR, this will include the PforR launching at the Federal Health Council (COFESA) and capacity building from the MSN and the World Bank teams. In addition, the signing of Framework Agreements with the provinces at earlier stages will help to mitigate the sectoral risk. Page 48 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 112. Institutional capacity for implementation is rated as Substantial. The proposed Program will be the first PforR operation in the health sector in Argentina. Although the MSN has more than 20 years of experience implementing World Bank-funded results-based projects, moving from World Bank processes to a PforR represents a significant change in accountability and exposes the MSN to the risk of not receiving funding if the DLI targets are not achieved. In addition, since the Government program includes some activities that have been supported through traditional Investment Project Financing (IPF) operations with arrangements that stem from the World Bank-funded nature of the Projects, the MSN will have to develop a normative framework to ensure the continuity of the implementation arrangements for the mentioned lines of work regardless of World Bank financing. A delay in the development of this framework could affect the implementation of activities required to achieve certain DLIs. To mitigate these risks, it is expected that the development of the normative framework under RA1 will be issued prior to Board date. Plus, implementation support and capacity building activities will be elaborated and agreed with the counterparts for supporting the transition process during implementation, as required. In addition, a Program Coordinator will be appointed to ensure the day-to-day implementation of the relevant milestones related to the DLIs, and a team of key staff will be designated as focal points in the relevant directorates of MSN and MSP to ensure timely coordination for the activities to support the achievement of the DLI targets. 113. The overall fiduciary risk is considered Substantial. The key fiduciary risks that underpin the Substantial risk rating are the following: (i) the MSN’s unfamiliarity with the PforR Instrument in terms of fiduciary arrangements; (ii) risk of inadequate planning for transferring funds to provinces; (iii) delays in the availability of funds for Program activities; (iv) potential omission in verifying firms eligibility before awarding the contract; (v) delays in the presentation of audit reports may increase the risk of financial inaccuracies or irregularities going unaddressed for a prolonged period of time; (vi) potential delays in implementation arising from the time to prepare technical specifications and conduct technical evaluation, as well as delays in obtaining the permissions to import and pay for them that could affect the procurement of specific goods; (vii) as the national legislation does not count on standards for determining qualification criteria, there is a risk of applying restrictive requirements on bidding documents; and (viii) based on the sample of processes implemented under the UNDP regime, it was identified that a single activity implemented through direct contracting represented 82 percent of the total amount, though when analyzing the total number of activities this method reduces to 17 percent. Although mitigation measures have been identified for all these risks at the end of the assessment, their effectiveness will only be determined during the Program’s execution phase. Therefore, the fiduciary risk is still considered Substantial even after implementing the mitigation measures due to the likelihood of occurrence. The risk will be continuously monitored and reevaluated during the implementation phase. To address the identified risks, the proposed measures for strengthening systems capacity and implementing mitigation actions include the following: (i) the Bank’s fiduciary teams will provide close implementation support and the Borrower will prepare a POM including the recommendations arising from the fiduciary assessment; (ii) a detailed disbursement plan with clear timelines and accountabilities will be established and communicated regularly, while also providing training and capacity-building activities to provincial authorities; (iii) disbursement of funds to an MSN account held in the Banco de la Nación Argentina (BNA) denominated in US dollars; (iv) establish clear deadlines for the completion and submission of audit reports, as well as implement an effective coordination between MSN, the Government Supreme Auditing Institution (AGN), and Ministry of Economy to monitor the progress and identify any potential delays; (v) the implementing agency will be required to comply with the World Bank’s Anticorruption Guidelines (ACG) and also verify the firms eligibility before awarding a contract, which will be monitored ex post by the external auditor. Adittionally, the implementing agency will follow a clear reporting process for any Page 49 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) allegations of fraud and corruption within the Program to ensure that the Bank is promptly informed; (vi) promote internal procedures to enable greater efficiency that will be assessed during supervision missions applying the baseline performance indicators detailed in the fiduciary systems assessment to identify any bottlenecks; (vii) apply qualification requirements that enable competition (including the possibility of foreign bidders to submit a bid following the national standard bidding document); and (viii) the POM will include a requirement to apply competitive methods as the default approach whenever applicable following the national legislation and UNDP framework. . Page 50 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) ANNEX 1. RESULTS FRAMEWORK MATRIX Results Framework COUNTRY: Argentina Program for Effective Universal Health Coverage and National Health System Integration Program Development Objective(s) To support improvements in: (a) the equitable and effective coverage of public health services, and (b) the efficiency of the health system. Program Development Objective Indicators by Objectives/Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline End Target Equitable and Effective Coverage of Public Health Services Population with Basic Effective Coverage (Percentage) DLI 2.1 35.00 45.00 Percentage of women aged 30-74 with diagnosed breast cancer that receives timely treatment (as registered at individual level) 47.70 56.00 (Percentage) Efficiency Savings in the purchase of essential medicines relative to the DLI 6.2 No Yes retail price at the time of the award (Yes/No) . Page 51 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) . Intermediate Results Indicator by Results Areas RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target Results Area 1: Consolidated and Institutionalized Health Financing Mechanisms Funds transferred by Provincial Ministries of Health (MSP) to healthcare providers to strategically purchase an essential health 0.00 60.00 service package (Percentage) Execution of the approved budget line of integrated transfers to Provincial Ministries of Health (MSP) adjusted for results within 0.00 85.00 the National Integrated Health Plan (NIHP) (Percentage) Results Area 2: Increased Equitable and Effective Coverage to health services Population with outpatient mental health visits to primary 176,329.00 484,120.00 healthcare (Number) Survivors of gender-based violence (GBV) with public health 796.00 3,000.00 coverage that receive healthcare services for GBV (Number) Women aged 50-69 years with a mammography according to 12.89 40.00 protocol and registered (Percentage) Children accessing high complexity services for selected 1,400.00 2,500.00 congenital cardiopathies and pediatric cancers (Number) Results Area 3: Improved Quality and Integration of Care in the Public subsector Primary Healthcare facility certified as a facility committed to 0.00 2,500.00 quality, which includes climate standards (Number) Provinces implementing activities or regulatory actions for the protection of the population against Non-communicable diseases 0.00 12.00 (NCD) and risk factors (Number) Provinces with georeferenced orientation teams to recognize, medically manage, and refer gender-based violence (GBV) 0.00 24.00 survivors to appropriate services (Number) Page 52 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline End Target Provinces implementing the International Patient Summary (IPS) 0.00 18.00 (Number) International Patient Summary (IPS) shared through the national 0.00 16,000.00 interoperability bus (Number) Percentage of claims/complaints registered on the 0800-line 74.00 85.00 solved in a timely manner by the Program (Percentage) Mammography Centers certified with a quality label in breast 0.00 34.00 cancer diagnostics (Number) Jurisdictions integrating the pediatric cancer network (Number) 0.00 5.00 Results Area 4: Improved Efficiency Stock control of medicines for mental health in a digital 70.00 90.00 management system (Percentage) Number of platforms registered and evaluated for digital 23.00 40.00 prescriptions (Number) Action plan to implement Federal Health License according to Decree regulating Law 27,553 on electronic or digital No Yes prescriptions (Yes/No) . Page 53 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) . Monitoring & Evaluation Plan: PDO Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection A beneficiary with Basic Effective Coverage is the one who has received at least one essential health service in the last 12 month. The essential The National Directorate health services are selected of Provincial Systems cost-effective health Strengthening (DNFSP) services, mainly focused in generates monthly NCD prevention and reports of effective control, maternal and health coverage using childcare, mental health, Sumar Roster GBV survivor related Sumar Management System; Population with Basic Effective Coverage services, reproductive Monthly Program DNFSP Sumar Health services health, among others. The databases database; National indicator is measured as: Institute of Statistics and Censuses (INDEC) and Numerator: Eligible National Directorate of population with effective Health Statistics and health coverage. Information (DEIS) Denominator: Total eligible statistics. population. Eligible population is those without formal insurance or covered only by the public sector. Percentage of women aged 30-74 with Numerator: Number of Annual Screening Databases of the Sumar DNFSP and INC Page 54 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) diagnosed breast cancer that receives eligible women aged 30-74 Information Program - DNFSP that timely treatment (as registered at years that initiated System are complemented by individual level) treatment for breast (SITAM) two information systems cancer in the last year. and/or Argent managed by the Denominator: Estimated ina National Cancer Institute number of new cases of Institutional (INC): RITA that is a eligible women aged 30-74 Tumor register of tumors years with breast cancer. Registry (RITA) diagnosed and/or Eligible women are those and/or Sumar treated in the hospital; without formal health Health and SITAM, that is an coverage or with public services online system that health coverage database registers patients that exclusively. have attended a healthcare facility to receive a prevention, diagnosis and/or treatment of breast, colon, or cervical cancer. At the moment of award, the price of the winning bid will be The National Ministry of compared with the retail Health (MSN) has Reports form price registered in purchased the revised the National Alphabeta (last available Savings in the purchase of essential package of essential National Directorate of Directorate of update), taking into medicines relative to the retail price at medicines with at least One time Medicines and Health Medicines and account an average of the time of the award seventy percent (70 Technologies Health the laboratories that bid percent) savings in relation Technologies with similar to the retail price at the presentations in that time of the award line, maintain active commercialization licences by National Page 55 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Administration of Drugs, Food and Technology (ANMAT) and have . updated the price. Page 56 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) . Monitoring & Evaluation Plan: Intermediate Results Indicators Methodology for Data Responsibility for Data Indicator Name Definition/Description Frequency Datasource Collection Collection Numerator: Amount of funds transfers from MSP The DNFSP collects every to healthcare providers to Funds transferred by Provincial Ministries month statements purchase an essential Statements of Health (MSP) to healthcare providers to reports form the package of health services. Annual from DNFSP strategically purchase an essential health jurisdiction Denominator: Total provinces service package implementing the amount of funds received Program by MSP from MSN to implement the Program Once the Administrative Decision that distributes the resources approved Numerator: execution of by the Budget Law is the budget lines identified published and uploaded for monetary transfers to Integrated to the Integrated Execution of the approved budget line of MSP, conditioned to Financial Financial Information integrated transfers to Provincial results. General Directorate for Information System Internet (e- Ministries of Health (MSP) adjusted for Denominator: budget lines Annual Planning and Budgetary System SIDIF), the Integrated results within the National Integrated approved by the Budget Control Internet (e- Financial Information Health Plan (NIHP) Law corresponding to the SIDIF) System Internet (e-SIDIF) budget lines identified for report verifies the monetary transfers to the budgetary resources for MSP conditioned to results each budget item and its corresponding execution. Number of eligible Sumar The DNFSP will provide DNFSP and National Population with outpatient mental health population with mental Annual Program the National Directorate Directorate of visits to primary healthcare health, suicide attempts, databases of Comprehensive Comprehensive Page 57 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) and episodic use of alcohol Approach to Mental Approach to Mental and other psychoactive Health and Problematic Health and Problematic substances consultations, Consumption informatio Consumption in primary healthcare n, using Sumar Roster facilities within one year. Management System The eligible population is and Sumar Health those with public health services database, about coverage. outpatient visits at primary healthcare services for mental health. This information will be registered at individual basis. The DNFSP will provide the Directorate of Gender and Diversity Number of women with (DGyD) information, public health coverage that using Sumar Roster Survivors of gender-based violence (GBV) have received a healthcare Sumar Management System with public health coverage that receive service included in the Annual Program and Sumar Health DNFSP and DGyD healthcare services for GBV package of services related databases services database, about with gender-based violence healthcare services (GBV) provided in relation to GBV. The information will be registered at individual basis. Numerator: Eligible women SITAM and The INC manages two aged 50-69 years with a RITA managed information Systems: (i) Women aged 50-69 years with a registered mammogram by INC and SITAM, that is an online mammography according to protocol and Annual DNFSP and INC according to protocol Sumar system that registered (every two years) Program registers patients that Denominator: Eligible Databases – have attended a Page 58 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Women aged 50-69 years MSN healthcare facility to with public health coverage receive a prevention, (every two years) diagnosis and/or treatment of breast, Eligible women are those colon, or cervical cancer; without formal insurance and (ii) RITA that is a or covered only by the register of tumors public sector. diagnosed and/or treated in the hospital. Sumar Health services database will be used to complement both systems. Number of children with The information will be access to high complexity collected by the DNFSP Children accessing high complexity services for congenital and the Directorate of DNFSP System services for selected congenital cardiopathies and pediatric Annual Integrated Health DNFSP s cardiopathies and pediatric cancers cancers, according to Services Networks. The DNFSP information data will be registered at systems. individual basis. Number of primary The National Directorate healthcare facilities, of Primary Healthcare registered at the Federal and Community Health National Directorate of Registry of Health Facilities will coordinate the Primary Healthcare and (REFES), that implement a Research implementation of the Primary Healthcare facility certified as a Community Health and self-assessment instrument Electronic self-assessment facility committed to quality, which Annual National Directorate of to evaluate quality Data Capture instrument to evaluate includes climate standards Quality in Healthcare standards. (Redcap) quality standards at Services and Health The assessment is related primary healthcare Regulation to the Quality and Tool for facilities. Evaluation the primary healthcare results will be managed certification that will be using Research Page 59 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) developed under DLI 5.1 Electronic Data Capture (Redcap) and information will be provided by primary healthcare services. The National Directorate of Quality in Healthcare Services and Health Regulation oversees the National Quality Plan. Number of provinces that implement some of the following actions: - Design an action The National Directorate Provinces implementing activities or plan for alcohol of Integral Management regulatory actions for the protection of consumption National Directorate of Public of NCD will assess the population against Non- - Implement actions Annual Integral Management documents documents submitted by communicable diseases (NCD) and risk in accordance with the of NCD provinces in relation to a factors National Law of healthy set of quality standards. nutrition - Implement a comprehensive tobacco control plan The National Directorate for gender and diversity Number of provinces implement the Provinces with georeferenced orientation where at least five percent “Comprehensive teams to recognize, medically manage, of its healthcare facilities Surveys from Annual healthcare in situations DGyD and refer gender-based violence (GBV) have trained teams to the DGyD of GBV. Tools for health survivors to appropriate services assist GBV victims and are teams". Those georeferenced. healthcare teams trained in the Page 60 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) implementation of the guideline and that submit the information required for facility georeferenced will be consider for this indicator. Through the National Digital Health Network (Red Nacional de Salud IPS implementation means Digital), the MSN aims at that at least one domain in ensuring the National each jurisdiction can interoperability of the Digital Health National Directorate of Provinces implementing the International request or send/share Health Information Biannually Network (Red Health Systems Patient Summary (IPS) clinical information Systems throughout the Nacional de Information through the National country. Through this Salud Digital) Digital Health Network network, clinical (interoperability bus). information can be shared between the different levels of care and jurisdictions. Through the National Digital Health Network (Red Nacional de Salud National Digital), the MSN aims at One time International Patient Summary (IPS) Digital Health ensuring the National Directorate of at the end shared through the national IPS sheared Network (Red interoperability of the Health Systems of the interoperability bus Nacional de Health Information Information project Salud Digital) Systems throughout the country. Through this network, clinical information can be Page 61 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) shared between the different levels of care and jurisdictions. Numerator: Number of sequences generated by Reports prepared by the claims/complaints on the Coordination of Public 0800.222.7100 line Coordination Information and answered within 15 of Public Communication of the Percentage of claims/complaints working days in the last 12 Information MSN through the registered on the 0800-line solved in a Annual DNFSP months. and sequence registry used timely manner by the Program Denominator: total number Communicatio by SUATS (Unified of sequences generated by n of the MSN Health Telephone claims/complaints on the Assistance System) and 0800.222.7100 line in the reported to the DNFSP. last 12 months. The indicator measures the number of mammography centers certified with a quality label in breast The INC is responsible cancer diagnostic according for the audit of the to the compliance with mammography centers. quality standards An administrative act is Mammography Centers certified with a established in the "Manual Annual INC issued through the INC quality label in breast cancer diagnostics for the evaluation of Electronic Management quality and safety System (GDE) once the standards in breast center has been diagnostic services" certified prepared by the INC. It includes accredited or re- accredited center. Jurisdictions integrating the pediatric Number of jurisdictions Directorate of Directorate of Integrated Reports prepare by the Annual cancer network that have at least one Integrated Health Services Coordination Center Page 62 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) healthcare facility Health Networks-INC integrating the pediatric Services cancer network Networks-INC National Directorate of Numerator: primary Medicines and Health healthcare facilities that Technologies and adhere to the digital stock Integral Monthly reports through Stock control of medicines for mental National Directorate of control strategy. Annual Reporting the Integral Reporting health in a digital management system Comprehensive Denominator: primary System System Approach to Mental healthcare facilities that Health and Problematic receive mental health kits Consumption Through the National Digital Health Network The indicator measured the National (Red Nacional de Salud number of platforms that Directorate of Digital), the MSN aims at National Directorate of Number of platforms registered and are evaluated according to Annual Health ensuring the Health Systems evaluated for digital prescriptions protocols established by Systems interoperability of the Information the MSN (Decree 98/2023, Information Health Information regulation of Law 27,553) Systems throughout the country The indicator monitors the design of an action plan (a technical document) for the implementation of the Action plan to implement Federal Health Federal Health License One time Secretariat for License according to Decree regulating throughout the national at the end Technical document Secretariat for Quality in Quality in Law 27,553 on electronic or digital territory (including the of the published Health Health prescriptions operational steps and project schedules, as well as the methodology of adhesion or registration to the FEDERAL SANITARY Page 63 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) LICENSE). The Federal Health License is referred to all licenses of health professionals, registered and recorded in the Federal Network of Registers of Health Professionals (REFEPS) and determines a unique ID for health professionals that allows to univocally identifies health professionals in the digital . prescription system. Page 64 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) . ANNEX 2. DISBURSEMENT LINKED INDICATORS, ARRANGEMENTS AND VERIFICATION PROTOCOLS . Disbursement Linked Indicators Matrix DLI_TBL_MATRIX DLI 1 Consolidated and institutionalized health financing mechanisms Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Text 38,000,000.00 12.67 Period Value Allocated Amount (USD) Formula Baseline - Prior Results - 20,000,000.00 See DLR 1.1 and 1.4 2024-2026 - 18,000,000.00 See DLR 1.2 and 1.3 DLI_TBL_MATRIX DLR 1.1 Administrative act for the integrated transfer mechanism from the Nation to the Provinces and its related Annexes DLI 1.1 approved (Decree, Resolution) Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 10,000,000.00 3.33 Period Value Allocated Amount (USD) Formula Baseline No Prior Results Yes 10,000,000.00 Accomplishment of Administrative Act Page 65 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 2024-2026 Yes 0.00 - DLI_TBL_MATRIX DLR 1.2 Annual creation of Budgetary Line for National Integrated Health Plan (NIHP) including the financial integrated DLI 1.2 capitation transfers Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 12,000,000.00 4.00 Period Value Allocated Amount (USD) Formula Baseline No Prior Results 0.00 2024-2026 Yes 12,000,000.00 US$4 million annually on the approval of the budgetary line DLI_TBL_MATRIX DLI 1.3 DLR 1.3 Number of provinces with signed sections of the Participation Agreement that pertain to the Program Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process Yes Number 6,000,000.00 2.00 Period Value Allocated Amount (USD) Formula Baseline 0.00 Prior Results 0.00 2024-2026 24.00 6,000,000.00 US$250,000 per each duly signed Participation Agreement up to US$6,000,000 Page 66 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_MATRIX DLR 1.4 Administrative act for the creation of a National Fund for High Complexity Diseases based on the institutionalization DLI 1.4 of the National Fund for Equity in Health mechanism (Decree, Resolution) Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 10,000,000.00 3.33 Period Value Allocated Amount (USD) Formula Baseline No Prior Results Yes 10,000,000.00 Accomplishment of Administrative Act 2024-2026 Yes 0.00 - DLI_TBL_MATRIX DLI 2 Population with basic effective coverage Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Text 47,000,000.00 15.67 Period Value Allocated Amount (USD) Formula Baseline - Prior Results 0.00 2024-2026 - 47,000,000.00 See DLR 2.1 Page 67 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_MATRIX DLI 2.1 DLR 2.1 Population with basic effective coverage Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Percentage 47,000,000.00 15.67 Period Value Allocated Amount (USD) Formula Baseline 35.00 Prior Results 0.00 2024-2026 45.00 47,000,000.00 US$1,958,333 per 0.25 percent increase up to US$47 million, in Y2 from 35 percent & Y3 from highest previously disbursed result DLI_TBL_MATRIX DLI 3 Coverage of children with Measles, Mumps, and Rubella (MMR) vaccination registered at individual level Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Text 48,000,000.00 16.00 Period Value Allocated Amount (USD) Formula Baseline - Prior Results 0.00 2024-2026 - 48,000,000.00 See DLR 3.1 Page 68 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_MATRIX DLI 3.1 DLR 3.1 Personalized registry dose applied at school entry Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Percentage 48,000,000.00 16.00 Period Value Allocated Amount (USD) Formula Baseline 38.85 Prior Results 0.00 2024-2026 85.00 48,000,000.00 US$1,040,087 per 1 percent increase up to US$48,000,000, in Y1 from 38.85 percent & in Y2/3 from highest previously disbursed result DLI_TBL_MATRIX DLI 4 Timely breast cancer treatment and registration Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Text 23,000,000.00 7.67 Period Value Allocated Amount (USD) Formula Baseline - Prior Results 0.00 2024-2026 - 23,000,000.00 See DLR 4.1 Page 69 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_MATRIX DLI 4.1 DLR 4.1 Women aged 30-74 with diagnosed breast cancer that receive timely treatment (as registered at individual level) Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome Yes Percentage 23,000,000.00 7.67 Period Value Allocated Amount (USD) Formula Baseline 47.70 Prior Results 0.00 2024-2026 56.00 23,000,000.00 US$692,771 per 0.25 percent increase up to US$23,000,000, in Y2 from 47.7 percent and in Y3 from highest previously disbursed result DLI_TBL_MATRIX DLI 5 Implementation of Quality and Climate Standards for Healthcare Facilities Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process Yes Text 40,000,000.00 13.33 Period Value Allocated Amount (USD) Formula Baseline - Prior Results - 10,000,000.00 See DLR 5.3 2024-2026 - 30,000,000.00 See DLR 5.1 to 5.2 Page 70 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_MATRIX DLI 5.1 DLR 5.1 Administrative act of creation of the Quality Tool for primary healthcare which includes climate standards Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 5,000,000.00 1.67 Period Value Allocated Amount (USD) Formula Baseline No Prior Results 0.00 2024-2026 Yes 5,000,000.00 Accomplishment of administrative act DLI_TBL_MATRIX DLR 5.2 Inpatient public health facilities certified as facility committed to quality, which includes climate standards, DLI 5.2 according to MSN Resolution 1744/21 Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process Yes Number 25,000,000.00 8.33 Period Value Allocated Amount (USD) Formula Baseline 15.00 Prior Results 0.00 2024-2026 135.00 25,000,000.00 US$208,333 per facility up to US$25 million Page 71 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_MATRIX DLI 5.3 DLI 5.3 Creation of the pediatric oncology network Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 10,000,000.00 3.33 Period Value Allocated Amount (USD) Formula Baseline No Prior Results Yes 10,000,000.00 Achievement of administrative act 2024-2026 Yes 0.00 - DLI_TBL_MATRIX DLI 6 Savings in the purchase of essential medicines Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Text 39,250,000.00 13.08 Period Value Allocated Amount (USD) Formula Baseline - Prior Results 0.00 2024-2026 - 39,250,000.00 See DLR 6.1 & 6.2 DLI_TBL_MATRIX DLI 6.1 DLR 6.1 Integral analysis and revision of the package of essential medicines Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 11,956,022.00 3.99 Period Value Allocated Amount (USD) Formula Page 72 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Baseline No Prior Results 0.00 2024-2026 Yes 11,956,022.00 Integral analysis and revision of the package of essential medicines completed DLI_TBL_MATRIX DLI 6.2 DLR 6.2. 70 percent savings in the purchase of essential medicines relative to the retail price at the time of award Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 27,293,978.00 9.10 Period Value Allocated Amount (USD) Formula Baseline No Prior Results 0.00 2024-2026 Yes 27,293,978.00 Achievement of saving target DLI_TBL_MATRIX DLI 7 Argentina’s Integrated Health Services Plan (PAISS) Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Text 21,000,000.00 7.00 Period Value Allocated Amount (USD) Formula Baseline - Prior Results 0.00 Page 73 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 2024-2026 - 21,000,000.00 See DLR 7.1 & 7.2 DLI_TBL_MATRIX DLI 7.1 DLR 7.1 Approval of Argentina’s Integrated Health Services Plan (PAISS) Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 20,000,000.00 6.67 Period Value Allocated Amount (USD) Formula Baseline No Prior Results 0.00 2024-2026 Yes 20,000,000.00 Accomplishment of administrative act DLI_TBL_MATRIX DLI 7.2 DLR 7.2 Implementation of Argentina’s Integrated Health Services Plan (PAISS) Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 1,000,000.00 0.33 Period Value Allocated Amount (USD) Formula Baseline No Prior Results 0.00 2024-2026 Yes 1,000,000.00 Action Plan to Implement the PAISS in place Page 74 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_MATRIX DLI 8 Administrative act for digital prescription Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome No Text 10,000,000.00 3.33 Period Value Allocated Amount (USD) Formula Baseline - Prior Results - 10,000,000.00 See DLR 8.1 2024-2026 - 0.00 - DLI_TBL_MATRIX DLI 8.1 DLR 8.1 Digital Prescription Approval Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Outcome No Yes/No 10,000,000.00 3.33 Period Value Allocated Amount (USD) Formula Baseline No Prior Results Yes 10,000,000.00 Accomplishment of administrative act 2024-2026 Yes 0.00 - Page 75 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_MATRIX DLI 9 Adaptation and mitigation strategies for climate change Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Text 33,000,000.00 11.00 Period Value Allocated Amount (USD) Formula Baseline - Prior Results - 10,000,000.00 See DLR 9.1 2024-2026 - 23,000,000.00 See DLR 9.2 DLI_TBL_MATRIX DLI 9.1 DLR 9.1 Administrative act approving the Health and Climate Change Strategy Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process No Yes/No 10,000,000.00 3.33 Period Value Allocated Amount (USD) Formula Baseline No Prior Results Yes 10,000,000.00 Accomplishment of administrative act 2024-2026 Yes 0.00 - Page 76 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_MATRIX DLI 9.2 DLR 9.2. Number of provinces with provincial health and climate change plans approved Type of DLI Scalability Unit of Measure Total Allocated Amount (USD) As % of Total Financing Amount Process Yes Number 23,000,000.00 7.67 Period Value Allocated Amount (USD) Formula Baseline 6.00 Prior Results 0.00 2024-2026 9.00 23,000,000.00 US$7,666,667 per Province up to US$23 million . Verification Protocol Table: Disbursement Linked Indicators DLI_TBL_VERIFICATION DLI 1 Consolidated and institutionalized health financing mechanisms Description See DLR 1.1 to 1.4 Data source/ Agency See DLR 1.1 to 1.4 Verification Entity See DLR 1.1 to 1.4 Procedure See DLR 1.1 to 1.4 DLI_TBL_VERIFICATION DLR 1.1 Administrative act for the integrated transfer mechanism from the Nation to the Provinces and its related DLI 1.1 Annexes approved (Decree, Resolution) This indicator monitors the consolidation and institutionalization of health financing mechanisms to ensure the availability of funds to increase quality and access to a package of essential healthcare services. Specifically, it monitors the creation of an integrated transfer mechanism from MSN to MSP. This administrative act and its related Annexes should include: (i) Description description of the methodology for calculating the transfers, including methodology to calculate the capita value (based on the costing of a cost-effective benefit plan, currently the Sumar benefit package and in the future that which is aligned to the PAISS) and the definition of the population without formal health coverage on which the total transfer will be calculated Page 77 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) (currently based on those enrolled under the Sumar Program); (ii) the description of the financial flow incorporating the three levels: Nation, Province and health facilities; (iii) the payment modalities to health facilities for the health services delivered to the enrolled population (currently the Provincial Nomenclature valued); (iv) the roles and functions of each party involved in the process; (v) the mechanism for reporting the use of funds (from province to Nation), and (vi) the obligations set out for in the Program Action Plan and the Anti-corruption Guidelines; and (vii) the corresponding sections of the participating agreement model to be signed between the Nation and the Province and between the Province and the Health Provider. Data source/ Agency MSN Verification Entity National Internal Audit Agency (SIGEN) Procedure Administrative act published in the boletin oficial. DLI_TBL_VERIFICATION DLR 1.2 Annual creation of Budgetary Line for National Integrated Health Plan (NIHP) including the financial integrated DLI 1.2 capitation transfers In the first year, the indicator will inform on the MSN’s request to the National Budget Office (ONP) to open a programmatic category in Administrative and Financial Services (SAF) 310’s budget and the notification of its granting. In the following Description years, it will monitor the maintenance of the programmatic line for NIHP, and verifying the credits assigned for the execution corresponding to the financial integrated capitation transfers under the NIHP. Data source/ Agency MSN Verification Entity SIGEN For each budget year, the existence of the enabled programmatic category and the credit associated with said category in Procedure the budget of Administrative and Financial Services (SAF) 310 will be verified through a report from the Integrated Financial Information System Internet (e-SIDIF). DLI_TBL_VERIFICATION DLI 1.3 DLR 1.3 Number of provinces with signed sections of the Participation Agreement that pertain to the Program This indicator monitors the consolidation and institutionalization of health financing mechanisms that will ensure the availability of funds to increase quality and access to a package of essential healthcare services. Specifically, it monitors the Description number of provinces that participate in the transfer mechanism through the signing of the sections of a Participation Agreement that pertain to the Program with the MSN. Page 78 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Data source/ Agency MSN Verification Entity SIGEN Procedure Sections of the Participation Agreement that pertain to the Program signed by MSN and MSP DLI_TBL_VERIFICATION DLR 1.4 Administrative act for the creation of a National Fund for High Complexity Diseases based on the DLI 1.4 institutionalization of the National Fund for Equity in Health mechanism (Decree, Resolution) This indicator monitors the consolidation and institutionalization by the MSN of the health financing mechanism aiming at providing effective access to a high-complexity diseases benefit package. This administrative act should include: (i) a methodology to calculate the transfer to the high complexity fund, including the description of the capita value; (ii) a description of the financial flow; (iii) the mechanism to pay high complexity services provided to the population with public Description health coverage; (iv) the roles and functions of participant entities involved in the process; (v) the strategy to finance the Fund; and (vi) the corresponding sections of the participating agreement model to be signed between the Nation and the Province so that the population with public health coverage of each Jurisdiction receives the services included in the Benefit Plan for high-complexity disease. Data source/ Agency MSN Verification Entity SIGEN Procedure Administrative act published in the boletín oficial DLI_TBL_VERIFICATION DLI 2 Population with basic effective coverage Description See DLR 2.1 Data source/ Agency See DLR 2.1 Verification Entity See DLR 2.1 Procedure See DLR 2.1 Page 79 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_VERIFICATION DLI 2.1 DLR 2.1 Population with basic effective coverage A beneficiary with Basic Effective Coverage is the one who has received at least one essential health service in the last 12 month. The essential health services are selected cost-effective health services, mainly focused in NCD prevention and Description control, maternal and childcare, mental health, GBV survivor related services, reproductive health, among others. The indicator is measured as: Numerator: Eligible population with effective health coverage. Denominator: Total eligible population. Eligible population is those without formal insurance or covered only by the public sector. Data source/ Agency Sumar Program - MSN Verification Entity SIGEN Compliance with targets can be verified through Sumar Program Databases (Sumar Roster Management System; Sumar Procedure Health services database; INDEC and DEIS statistics) DLI_TBL_VERIFICATION DLI 3 Coverage of children with Measles, Mumps, and Rubella (MMR) vaccination registered at individual level Description See DLR 3.1 Data source/ Agency See DLR 3.1 Verification Entity See DLR 3.1 Procedure See DLR 3.1 DLI_TBL_VERIFICATION DLI 3.1 DLR 3.1 Personalized registry dose applied at school entry The indicator will be measured as: Numerator: Children registered at the individual level as vaccinated with booster doses Description of MMR vaccine at school entry (Source: Federal Vaccination Registry (NOMIVAC)). Denominator: Children of school entry age (Source: DEIS) Data source/ Agency NOMIVAC and DEIS – MSN Verification Entity SIGEN Procedure Compliance with the progress can be verified through the NOMIVAC, that records vaccinations at the individual level Page 80 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_VERIFICATION DLI 4 Timely breast cancer treatment and registration Description See DLR 4.1 Data source/ Agency See DLR 4.1 Verification Entity See DLR 4.1 Procedure See DLR 4.1 DLI_TBL_VERIFICATION DLI 4.1 DLR 4.1 Women aged 30-74 with diagnosed breast cancer that receive timely treatment (as registered at individual level) Numerator: Number of eligible women aged 30-74 years that initiated treatment for breast cancer in the last year. Description Denominator: Estimated number of new cases of eligible women aged 30-74 years with breast cancer. Eligible women are those without formal health coverage or with public health coverage exclusively. Data source/ Agency SITAM and/or RITA and/or Sumar Health services database Verification Entity SIGEN The INC manages two information Systems: (i) SITAM, that is an online system that registers patients that have attended a healthcare facility to receive a prevention, diagnosis and/or treatment of breast, colon, or cervical cancer; and (ii) RITA that Procedure is a register of tumors diagnosed and/or treated in the hospital. Sumar Health services database will be used to complement both systems. DLI_TBL_VERIFICATION DLI 5 Implementation of Quality and Climate Standards for Healthcare Facilities Description See DLR 5.1 to 5.3 Data source/ Agency See DLR 5.1 to 5.3 Verification Entity See DLR 5.1 to 5.3 Procedure See DLR 5.1 to 5.3 Page 81 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_VERIFICATION DLI 5.1 DLR 5.1 Administrative act of creation of the Quality Tool for primary healthcare which includes climate standards Administrative act (Decree, Resolution) for the creation of the self-assessment instrument to evaluate quality and climate Description adaptation standards at primary healthcare facilities. The tool would include 79 dimensions such as: identification of indigenous peoples, detection of gender violence, referral and counter-referral services. National Directorate of Primary Healthcare and Community Health and National Directorate for Quality in Healthcare Data source/ Agency Services and Health Regulation – MSN Verification Entity SIGEN Procedure Administrative act published in the boletín oficial DLI_TBL_VERIFICATION DLR 5.2 Inpatient public health facilities certified as facility committed to quality, which includes climate standards, DLI 5.2 according to MSN Resolution 1744/21 Number of Inpatient public health facilities, registered at REFES, that have received the recognition as a healthcare facility committed to quality after implementing the quality assessment tool established in the MSN resolution 1744/21. The assessment is part of the National Quality Plan (MSN Resolution 2546/21) and includes quality and climate standards. The National Directorate of Quality in Healthcare Services and Health Regulation coordinates the different steps to implement the assessments. The provinces select the inpatient facilities that will undergo the evaluation within the framework of the Description Federal Quality Network (MSN resolution 2546/21). The documentation that supports the evaluation will be shared through Research Electronic Data Capture (Redcap). The National Directorate for Quality in Healthcare Services and Health Regulation, after analyzing this documentation, will rate the commitment to quality of the facility with three levels: “initial”, “intermediate” and “advance”. The rate will be published in the REFES. Note: inpatient facilities specialized in elderly and mental healthcare are excluded Data source/ Agency REFES and Redcap Verification Entity SIGEN Compliance with the progress can be verified through REFES where inpatient facilities that have received the recognition Procedure are identified DLI_TBL_VERIFICATION DLI 5.3 DLI 5.3 Creation of the pediatric oncology network Description Administrative act for the designation of the Coordination Institution for the management of the network Page 82 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Data source/ Agency MSN Verification Entity SIGEN Procedure Administrative act published in the boletín oficial DLI_TBL_VERIFICATION DLI 6 Savings in the purchase of essential medicines Description See DLR 6.1 & 6.2 Data source/ Agency See DLR 6.1 & 6.2 Verification Entity See DLR 6.1 & 6.2 Procedure See DLR 6.1 & 6.2 DLI_TBL_VERIFICATION DLI 6.1 DLR 6.1 Integral analysis and revision of the package of essential medicines This indicator has the objective to support the integral analysis and revision of the list package of essential medicines being Description purchase by Remediar Program. The revision should be based in an analysis of new technologies, clinical guidelines, and the burden of disease. Data source/ Agency MSN Verification Entity SIGEN Procedure Administrative act published in the boletín oficial DLI_TBL_VERIFICATION DLI 6.2 DLR 6.2. 70 percent savings in the purchase of essential medicines relative to the retail price at the time of award MSN has purchased the revised package of essential medicines with at least seventy percent (70 percent) savings in relation Description to the retail price at the time of the award. Data source/ Agency MSN - National Directorate of Medicines and Health Technologies Verification Entity SIGEN Procedure At the moment of award, the price of the winning bid will be compared with the retail price registered in Alphabeta (last Page 83 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) available update), taking into account an average of the laboratories that bid in that line with similar presentation, that maintain active commercialization by the National Administration of Drugs, Food and Technology (ANMAT) and have updated the price. DLI_TBL_VERIFICATION DLI 7 Argentina’s Integrated Health Services Plan (PAISS) Description See DLR 7.1 & 7.2 Data source/ Agency See DLR 7.1 & 7.2 Verification Entity See DLR 7.1 & 7.2 Procedure See DLR 7.1 & 7.2 DLI_TBL_VERIFICATION DLI 7.1 DLR 7.1 Approval of Argentina’s Integrated Health Services Plan (PAISS) The administrative act of institutionalization of the PAISS may include, inter alia: (i) costing of the lines of care of the benefit package and evaluation of its financing; (ii) design of mechanisms for updating the lines of care, benefits and costs included Description in the country's benefit plan; (iii) protocols and care guidelines developed according to the needs foreseen for the PAISS; and (iv) protocols and care guidelines developed according to the needs foreseen for the PAISS. Data source/ Agency MSN Verification Entity SIGEN Procedure Administrative act published in the boletín oficial DLI_TBL_VERIFICATION DLI 7.2 DLR 7.2 Implementation of Argentina’s Integrated Health Services Plan (PAISS) Administrative act with the approval of the road map for the implementation of PAISS. The Action Plan will include the Description actions and timeline for working with the other subsystems of the health system to implement the PAISS. Data source/ Agency MSN Verification Entity SIGEN Procedure Administrative act published in the boletín oficial Page 84 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) DLI_TBL_VERIFICATION DLI 8 Administrative act for digital prescription Description See DLR 8.1 Data source/ Agency See DLR 8.1 Verification Entity See DLR 8.1 Procedure See DLR 8.1 DLI_TBL_VERIFICATION DLI 8.1 DLR 8.1 Digital Prescription Approval This administrative act supports the implementation of digital prescription in the country. The act defines the minimum data that must be recorded for the validity of digital prescriptions and sets the requirements for digital platforms, to guarantee that they protect the confidentiality and inviolability of the data, and the timely access of the users. The act establishes that the digital prescription should use the international standards to allow information exchanges among Description different actors through the National Digital Health Network. The act also creates the “Licencia Sanitaria Federal” (federal health license) which will include all the qualifying registrations of health professionals in the Red Federal de Registros de Profesionales de la Salud (federal network of health professional’s registry). This license will determine a unique ID for the health professional. This unique ID is key to support the achievement of an interoperable digital infrastructure, strengthening the exchange of health information for providing better health quality services to the population. Data source/ Agency MSN Verification Entity SIGEN Procedure Administrative act published in the boletín oficial DLI_TBL_VERIFICATION DLI 9 Adaptation and mitigation strategies for climate change Description See DLR 9.1 to 9.2 Data source/ Agency See DLR 9.1 to 9.2 Verification Entity See DLR 9.1 to 9.2 Page 85 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Procedure See DLR 9.1 to 9.2 DLI_TBL_VERIFICATION DLI 9.1 DLR 9.1 Administrative act approving the Health and Climate Change Strategy Administrative act that approves the Health and Climate Change Strategy. This act is a joint effort between the MSN and the Description Ministry of Environment and Sustainable Development. Data source/ Agency MSN Verification Entity SIGEN Procedure Administrative act published in the boletín oficial DLI_TBL_VERIFICATION DLI 9.2 DLR 9.2. Number of provinces with provincial health and climate change plans approved The provincial administrative act approving the plans may include the following elements: (i) creation of climate change Description tables in the MSP; (ii) improvement of vector-borne diseases (VBDs) surveillance; (iii) measurement of the climate footprint at hospital level Data source/ Agency MSN Verification Entity SIGEN Procedure Health & Climate change plans approved by provincial governments . Page 86 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) ANNEX 3. TECHNICAL ASSESSMENT A. Strategic Relevance and Technical Soundness 1. The proposed Program scope is informed by the findings of analytical work and the experiences of previous engagements 2. The Program’s Development Objective (PDO) is aligned with the National Integrated Health Plan (NIHP) and will support improvements in: (i) the effective and equitable access to high quality public health services, and (ii) the efficiency of the health system. The higher objective of the Program is to support the universal health coverage through the development of an integrated health system. The Program for Rresults (PforR) builds on successful ongoing and recently closed Bank-supported initiatives such as the Sumar and Proteger programs. Through the focus on explicit coverage of essential healthcare services, Argentina has made progress in terms of achieving universal health coverage, in particular with respect to service coverage. Since 2004, Argentina has been implementing a strategy to strengthen provincial health systems to improve access to essential health services for the population with Exclusive Public Health Coverage. This strategy begun with the implementation of Nacer Plan in the Northern regions of the country, focused on maternal and child health, and later expanded to the whole country and the entire population with the Sumar Program (Bank Projects P071025, P095515, P106735, P163345, and P174913). 3. From a strategic perspective, the Government program and the PforR are well-balanced with respect to incremental improvements to existing systems or processes and more transformational reforms to change the way the current healthcare system operates. One the one hand, activities and programs that have been previously initiated are being continued under the PforR and incremental improvements in existing indicators (see Disbursement-Linked Indicators (DLIs) 2 to 5) are being supported. On the other hand, the institutionalization of several programs and their consolidation (DLI 1) as well as activities to advance the integration of the different health sectors (in particular, DLI 7 with its support of a new benefit package) have the potential of truly transforming the health sector. 4. From a technical point of view, the RAs of the PforR are aligned with the “iron triangle” of healthcare which summarizes the interdependent relationship between three key intermediate objectives of healthcare systems: efficiency (directly related to costs), quality, and coverage (which is partially determined by access). This triangle represents the idea that it is difficult to achieve all three of these elements simultaneously. Cost or efficiency refers to the financial burden associated with healthcare services (including the cost of medical procedures, medications, and insurance) and the need to minimize the resources needed to produce such healthcare services. Quality refers to the level of care that patients receive, including the accuracy of diagnoses, the effectiveness of treatments, and the overall experience. Access refers to the availability and affordability of healthcare services, including the availability of medical providers and insurance coverage. The challenge with the iron triangle is that improving one element often negatively affects one or more. For example, increasing access to healthcare services may drive up costs, while improving the quality of care may reduce access for some patients. Balancing the three elements is a complex and ongoing challenge for policymakers, healthcare providers, and the public. 5. For almost 20 years, the Sumar Program has been the central element of a continuous strategy to improve the public health system in Argentina, as a strategic tool for organizational transformation and the strengthening of institutional capacities, which allowed the National Ministry of Health (MSN) to coordinate Page 87 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) efforts towards the achievement of prioritized health results, reducing coverage gaps. Like any project, Sumar’s initial implementation was confined in time and scope, for the fulfillment of the specific development objectives of the project. However, Sumar Program was able to implement innovative management instruments that break through different ministerial structures. Throughout its implementation, Sumar was supported by the Bank through an investment project, in which most of the operational management tools and instruments were defined within the project itself, with spillovers or positive externalities to different MSN areas, programs and projects. Thus, the Program’s institutionalization will take place when design and management elements that have proven effective, transcend the project framework and become guiding elements of national health policy. Thus, institutionalization includes processes of internalization and adoption of instruments and good practices by other actors, supporting a broader process of sustainability of the project, towards a program and then, towards a policy. 6. An exhaustive analysis of the experience of the Sumar Program78 indicates that seven institutional drivers have been critical for Sumar sustainability: (i) the program's normative strength (“legal architecture”); (ii) having a defined target population and service scope; (iii) using a vertically integrated transfer mechanism based on results; (iv) having developed an extensive explicit benefit package; (v) fostering a decentralized administration with national supervision and monitoring (a combination of stewardship and autonomy); (vi) the “flexible and dynamic structure” of the program which allows to produce changes in the program according to the context; and (vii) the gathering and systematization of data which allow to implement evidence-based strategies. These studies also found “bureaucratic integration” of the program, support from the Provincial Ministries of Health (MSP) and local authorities, inclusion into the provincial ministerial planning and organizational structure, implementation of training actions by the province and interaction with other national health programs in the province. 7. The trajectory of the Sumar Program is remarkable in view of the international evidence on results- based financing programs and their institutionalization; the PforR supports the transition from a program to a national policy, being part of the national strategic health plan. One key bottleneck to scaling up and institutionalizing results-based financing has been found to be related to Public Financial Management 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 results-based financing scheme and the existence of a purchasing unit are key obstacles to the sustainability and continuation of these schemes over time. As described above, in the case of Argentina’s Sumar Program, major advances in the purchasing capacity of the MSN have been made. The framework of the PforR provides the necessary elements for the definition of an integrated and comprehensive public policy based on the robust pillars from the Sumar Program and as part of the continuous process of institutionalization. 8. The Proteger Program (P133193) has made important contributions toward protecting vulnerable population groups against prevalent non-communicable diseases (NCD) risk factors. The Project implemented transfer-linked indicators from the MSN to MSP for improving the readiness of public health facilities to deliver high quality NCD-services for underserved population groups and expanding the scope of selected services. The results-based operation promoted an integrated, multi-sector approach toward reducing prevalence of NCD risk factors at the municipal and provincial level, including tobacco use and exposure to second-hand smoking, sodio consumption, obesity, and sedentarism. As for the Sumar Program, the continuous process of institutionalization 78“Programa Sumar: A sustainability study based on 10 years of implementing results-based financing in Argentina” and “Systematization and Deepening of Sumar Program’s Sustainability Assessment: Institutional Drivers and Subnational Enablers: Continuities, Challenges and Lessons Learned”. Page 88 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) of the Proteger Program towards the definition of an integrated and comprehensive public policy based finds the right framework through the PforR. 9. The proposed PforR will support four out of five pillars of the NIHP over the three-year period of 2023- 2025. As mentioned above, the three NIHP objectives are organized around five pillars: (i) equitable access; (ii) quality of care; (iii) efficiency; (iv) integration of health system and service delivery networks; and (v) health intelligence and data analysis for decision making. Each pillar includes specific strategic lines and activities. The PforR will support part of the NIHP for the period 2023-2025, considering the strategic lines and activities that are linked to the RAs. This sets the boundaries of the PforR, focusing on supporting the following strategic lines and activities: 1) the institutionalization of the Sumar Program; 2) gender diversity and gender-based violence (GBV); 3) mental health promotion; 4) quality of integrated healthcare with evaluation of health facilities; 5) quality of health promotion and regulations linked to reducing NCD risk factors (including epidemiological surveillance as part of efficient climate change actions (the provincial health and climate change plans must include mechanisms to improve the surveillance of vector-borne diseases (VBD); 6) the strategic purchasing of drugs; 7) roadmap for for the definition of the integrated health services package (Argentina Integrated Health Services Plan, PAISS); 8) the implementation of PAISS; and 9) health information systems. Table A3.1 shows the scope of the NIHP and the correspondence with PforR boundaries. The selection has been made based on the areas that are key and could achieve results in a three-year period, towards reaching the PforR development goals, and where the Bank support is relevant based on the long-term commitment with the related programs in the sector. Additionally, the selected budget lines to be supported by the PforR correspond to programs that historically have had very high levels of execution. Areas of the NIHP that are not included in the PforR are those activities that are in earlier stages of design and/or planning. Implementing them in the three-year time frame of the PforR would not be feasible. Table A3.1. Scope of the Government Program - NIHP and the PforR NIHP Pillar & Strategic PforR Results Areas (RAs) Activities Line 1: Equitable access to healthcare A. Capacity development in the MSN and MSP for strategic purchasing quality health services, with a gender and diversity approach. Consolidated and institutionalized health B. Development of a mechanism for the evaluation 1: Sumar Program, financing mechanisms (RA1) and prioritization of health services, within the provision of comprehensive review of Sumar Program’s health integrated services package. healthcare services. C. Access to high complexity health services financed with a fund designed for this purpose, based on the Equitable and effective coverage (RA2) current Sumar’s National Fund for Equity in Health (FONES). Equitable and effective coverage (RA2) A. Supporting the implementation of current national 2: Effective access and improved quality and integration legislation on gender and diversity. to health services (RA3) for women and the B. Supporting the implementation of the "National Equitable and effective coverage (RA2) LGBTQ+ population Plan for Gender and Diversity in Public Health and improved quality and integration from a gender Policies” (MSN Resolution 1886/2020). (RA3) perspective. C. Education and training of health teams and Equitable and effective coverage (RA2) technical areas of the jurisdictional ministries about and improved quality and integration Page 89 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) gender and GBV. (RA3) D. Implementation of the Clinical Guideline Equitable and effective coverage (RA2) “Comprehensive healthcare in situations of GBV. and improved quality and integration Tools for health teams". (RA3) E. Implementation of care lines to improve the access of women and the LGTBQ+ population with exclusive Equitable and effective coverage (RA2) public coverage to comprehensive healthcare. A. Supporting the National Law 26,657 on the Right to the Protection of Mental Health and the Equitable and effective coverage (RA2) implementation of the Federal Strategy for a Comprehensive Approach to Mental Health. B. Jurisdictional capacities and resources master Equitable and effective coverage (RA2) planning to carry out the community mental health and improved quality and integration 3: Improved access strategy. (RA3) to continuity of care C. Roster of population under mental health program, for mental health. with severe illnesses, requiring follow-up and specific approaches. D. Development of flows and network’s processes between levels, implementation of coordination mechanisms considering quality and GBV approaches. E. Development and strengthening of jurisdictional mental health networks, including all levels of care. 2: Quality of healthcare Equitable and effective coverage (RA2) A. Supporting the National Plan for Quality in Health and improved quality and integration (2021-2024), approved by MSN Resolution 2546/2021. (RA3) 4: Strengthening the B. Implementation of a tool for evaluating good Equitable and effective coverage (RA2) quality of the practices in public hospitals and private health and improved quality and integration integrated care providers (“Providers committed to health quality”), (RA3) model in the public including climate considerations. sector including C. National user satisfaction survey. climate D. Work environment assessment in health providers. considerations. E. Training for health teams in patient safety, quality management and risk management. F. Design and implementation of clinical practice guidelines and quality of care protocols. A. Supporting the implementation of regulations for the promotion of health and the prevention of cardiovascular risk factors, including National Laws: Equitable and effective coverage (RA2) 5: Strengthening the 27,642 (“Promotion of Healthy Eating”), 26,905 and improved quality and integration implementation of a (“Reduction of salt consumption”), National Law (RA3) comprehensive 26,687 (“Tobacco Control”), 27,197 (“Fight against approach for NCD sedentary lifestyle”), 23,753 (“Diabetes”). care and risk B. Implementation of a comprehensive NCD approach factors. Improved Efficiency (RA4) model in the jurisdictions. C. Conducting population surveys for epidemiological surveillance. Page 90 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) D. Support for the certification process of health facilities for the detection and control of chronic NCD. E. Development of Core Competencies needed in health teams. F. Intersectoral strategies for health promotion. G. Capacity strengthening for the implementation of health promotion actions in the Municipalities. A. Support for the National Plan for Continuing Education in Health. 6: Strengthening the B. Development of an information management training and system for Human Talent in Health. education strategy C. Building a “Simulation and Training Center” for the for human improvement of different healthcare competencies. resources in health. D. Strengthening the management and accreditation systems for medical residencies. 3: Efficiency A. Strategic purchase and delivery of essential drugs. National Law 26,906 (“Traceability of Medicines””) and Remediar Program: Presidential Decree Improved Efficiency (RA4) 2724/2002, MSN Resolution 248/2020, MSN Resolution 1048/2021, National Law 27,553 (“Electronic prescription of drugs”). B. Mechanisms for the efficient and strategic 7: Comprehensive, purchase of high-priced drugs, considering the Improved Efficiency (RA4) efficient, and evaluation of health technologies. equitable C. Design of mechanisms for the efficient purchase of management Improved Efficiency (RA4) high-priced drugs. strategy for drugs D. Implementation a methodology for rapid health and health Improved Efficiency (RA4) technology assessment for prioritized lines of care. technology. E. Electronic prescription of drugs and digitalization of nominalized drug delivery carried out by health Improved Efficiency (RA4) facilities. F. Implementation of a National Fund for High Price Improved Efficiency (RA4) Prescription Drugs. G. Implementation of a National Fund for High Consolidated and institutionalized Complexity Health Interventions. mechanisms for health financing (RA1) 4: Integration and health services networks A. Roadmap for the implementation of an integrated Improved Efficiency (RA4) health services package (benefits package). 8: Definition of a B. Development of the regulatory framework for the health benefits implementation of the benefit package. package for the integration of C. Monitoring system of health services provision health systems between health systems. (PAISS). D. Improvements in information systems for cost recovery of health interventions provided to social security (“obras sociales”) beneficiaries. Page 91 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) A. Planning, monitoring and evaluation of jurisdictional 9: Strengthening the projects to strengthen health service networks. governance of the B. Strategies for the implementation and evaluation health system and of care coordination mechanisms for prioritized lines Improved Efficiency (RA4) integrated health of care. networks. C. Investment master plans for infrastructure and equipment with a network perspective. A. Development of interoperability standards to promote quality of care and an integrated model of care (MSN Resolution 189/2018 - National Strategy Equitable and effective coverage (RA2) for Digital Health 2018/2024; MSN Resolution and improved quality and integration 680/2018 - Standards; MSN Resolution 115/2019 – (RA3) 10: Strengthening of National Interoperability Network; MSN Resolution health information 2524/2019 – Guideline for Unique Health Identifier). systems. B. Continue the development of interoperable Equitable and effective coverage (RA2) electronic health records, including treatments, and improved quality and integration prescriptions and interventions. (RA3) C. Make progress in the implementation of the National Digital Health Network. D. Strengthening the Telehealth strategy. 5: Health intelligence 11: Design and A. Institutional capacity building for creating an area in implementation of charge of data centralization, data monitoring and health intelligence analysis of health information. tools. Results Area 1. Consolidated and institutionalized health financing mechanisms 10. The PforR will support the consolidation and institutionalization of health financing mechanisms that will ensure the availability of funds to finance increased access to healthcare services and improved quality of care (DLI 1). The Government will seek to achieve two specific results related to this DLI. The Government will seek to achieve two specific results related to this RA1 and its DLI: (i) ensuring the existence of mechanisms to transfer financial resources linked to results from the national to the provincial level. These funds will foster the provision of a package of health services following quality protocols for the population without formal insurance, continuing the Sumar Program mechanisms; and (ii) promoting improvements in quality of care by rewarding results at the provincial level, following the Proteger program logic. This will allow the harmonization and unification of the different MSN financial transfers to the provinces. This Disbursement-Linked Result (DLR) will measure the issuance of a norm establishing the mechanism, the creation and maintenance of a budgetary line for this purpose, and the number of provinces that signed the Umbrella Agreement that enforces the compliance with the institutional and implementation arrangements related to the implementation of the PforR Program. 11. Argentina has made important advances in coverage for high-complexity diseases, by including in 2012 the High-Complexity Perinatal Package for congenital malformations within the benefit package covered by the Solidarity Reinsurance Fund for Catastrophic Diseases under the Sumar Program. In 2019, with the addition of services for acute myocardial infarction, it became the high-complexity diseases Fund, which was renamed in 2020 as the FONES. The successful experience of the Federal Network of Congenital Cardiopathies (RFCC) implemented a robust system of economic incentives based on results to promote the participation of the provinces and hospitals in the network. It also included control mechanisms to ensure compliance with common standards, both Page 92 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) clinical and administrative. the Fedreal Network was also supported by a solid operational platform, including a system of norms and procedures, both clinical and administrative, and computerized management tools.79 12. The PforR will also support an institutionalization mechanism of the FONES as the second specific result under DLI 1. The corresponding DLR will track the institutionalization of the mechanism to finance the provision of high-complexity diseases interventions to the population exclusively covered by the public sector through the FONES. The FONES serves as a risk pool at the national level whose funds are used to make payments to authorized providers for the provision of services included in the High-Complexity Disease package. This package is defined by the National MSN according to a well-defined metholdology and currently covers congenital heart diseases, congenital malformations and selected cardiovascular procedures. Since this strategy has been supported through the different World Bank-funded Projects since 2010,80 while all the institutional and implementation arrengements are developed and operative, they are established through legal norms related to World Bank- funded Projects. In this regard, this DLR will measure the issuance of a norm institutionalizing the mechanism to cover the provision of the high-complexity diseases package through in-country systems and the creation and maintenance of a budgetary line for this purpose. Results Area 2. Increased equitable and effective coverage of health services for the eligible population 13. Recovering the universal health coverage gains that were erased by the COVID-19 pandemic is crucial . The prolonged economic crisis has intensified the pressure on the Argentine public sector. People at all stages of life experienced significant disruptions in healthcare services that will have significant impacts for the foreseeable future. In addition to the direct and indirect negative impact of the pandemic on the health sector, COVID-19 also increased the population that exclusively relies on the public sector (i.e., the population without social security coverage). 14. The PforR will support the continuation of the MSN’s program with the aim to increase the effective coverage of the otherwise uninsured population with essential health services (DLI 2). As it has been mentioned, the PforR will continue the support to the Sumar Program not only by ensuring the institutionalization of its results-based mechanism within national processes; but also by supporting the results supported by this program that ensure the increase in effective coverage of essential health services to the population without formal health insurance. 15. Routine immunization coverage has declined since 2017, and the decline was exacerbated by the COVID-19 pandemic. Argentina's vaccination schedule used to be one of the most comprehensive in the region, achieving great success in the past: the elimination of local cases of congenital rubella in 2009, poliomyelitis in 1984, diphtheria in 2006, neonatal tetanus in 2007; and the reduction by more than 96 percent of cases of liver transplants due to hepatitis A virus. However, by 2020, the coverage of vaccinations in children under one year of age recorded a drop of 19 percentage points compared to 2015 and of 8 points compared to 2019. 79 Zanetta, C. 2020 Conformación de la Red Federal de Cardiopatías Congénitas en Argentina. Case Study. Global Delivery Initiative – orld Bank Group. https://effectivecooperation.org/system/files/2021- 06/gdi_estudio_de_caso_argentina_cardiopatias_spanish.pdf 80 In 2010, the Nacer Plan included the financing of congenital heart diseases surgeries for children under six to continue reducing the Infant Mortality Rate by addressing the hard causes of deaths through the establishment of Solidarity Redistribution Fund. Later on, other high complexities diseases were included, such as inpatient neonatal care and congenital malformations, and coverage was extended to other population groups. Page 93 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 16. In this context, the PforR will support increasing the coverage of children with Measles, Mumps, and Rubella (MMR) vaccination at school entry (DLI 3). Based on a data standardization and consolidation effort, nominalized data will be stored through a national database. According to the Argentine Report on “the Impact of the SARS-CoV-2 Pandemic on National Vaccination Coverage 2020”,81 published in December 2021, the national vaccination coverage for the pre-pandemic period (2009-2019) showed a gradual and progressive decrease, with an average drop of ten points in that decade, especially in childhood immunization. Thus, for the year 2019, coverage did not exceed 90 percent in any of the vaccines in the National Vaccination Schedule, and in 2020, no vaccine in any age group exceeded a value of 80 percent coverage nationwide. At school entry, MMR vaccine coverage is declining, showing a 15-percentage point drop compared to 2015, and a 12-percentage point drop compared to 2019. As a result in 2020, the country faced the largest measles outbreak since the elimination of endemic circulation was recorded, with 174 confirmed cases, including one death. It is crucial to rapidly invest in efforts to increase coverage rates. 17. Argentina needs to make improvements in breast cancer screening to lower its relatively high case rates (intermediate indicator (IRI) 3). In Argentina, breast cancer is the first cause of death by tumors in women with an age-adjusted incidence rate of 212.4 cases per 100,000 inhabitants. Improving breast cancer screening rate is therefore a key public health priority for Argentina. Screening women to identify cancers before any symptoms appear contributes to the early detection and is critical for improving breast cancer outcomes and survival rates. Routine mammography screening in women over 40 years of age reduces cancer deaths by 16 percent and in women over 50 years of age by 20 to 30 percent. 18. Mental health is another public health problem that must be addressed through strategic actions. As a result, the NIHP for the first time has included the effective coverage of the uninsured population with mental health services as an explicit target. According to the first Argentine Study of Mental Health Epidemiology, published in the scientific journal Social Psychiatry and Psychiatric Epidemiology (2018), one in three Argentines over 18 years of age presented a mental health disorder at some point in their lives. The highest prevalence was anxiety disorders (16.4 percent), followed by mood disorders (12.3 percent), which included major depressive disorder, and in third place substance abuse disorders (10.4 percent). Of those studied, 29.1 percent had a single diagnosis, 12.6 percent had two or more diagnoses, and 5.7 percent had three or more diagnoses. As for gender differences, women were 85 percent more likely than men to have anxiety disorders, a finding consistent with other studies worldwide. This problem worsened during the COVID-19 pandemic, increasing new cases of mental health conditions, and worsening pre-existing ones. On the one hand, the complex situation affected people's mental health and, on the other, mental health services were severely affected or interrupted, given the need to prioritize emergency care. 19. To strengthen the approach to this problem from a comprehensive perspective and in accordance with National Law 26,657, the MSN developed the National Mental Health Plan 2021-2025, through a collaborative effort between different areas of government, civil society and cooperation agencies, including the representation in Argentina of the Pan American Health Organization (PAHO)/ World Health Organization (WHO). Its objective is to address mental health through actions to strengthen mental health services at the first level of care that include: (i) expansion of service provision (telemedicine), (ii) mental health stewardship, (iii) interdisciplinary mental health teams for the promotion, prevention and care in community mental health, (iv) capacity building 81 https://bancos.salud.gob.ar/recurso/ii-informe-sobre-el-impacto-de-la-pandemia-por-sars-cov-2-en-las-coberturas-nacionales-de Page 94 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) for professionals from different disciplines that will be incorporated to the mental health network for service delivery at community level. Results Area 3. Improved quality and integration of care in the public sector 20. Improving the access to health services may have only a modest impact if the quality of care remains poor. For instance, the 2018 Lancet Commission on High Quality Health Systems makes a compelling case for taking a health systems approach to improving quality and health outcomes at scale. Based on the global study, poor-quality care is now a bigger barrier to reducing mortality than insufficient access. 60 percent of deaths from conditions amenable to healthcare are due to poor-quality care, whereas the remaining deaths result from non- utilization of the health system. DLIs in this RA will contribute to ensuring that quality of care receives sufficient consideration, and will build on previous work, started under the World Bank supported Proteger Program. 21. In 2009, the MSN established the National Strategy for the Prevention and Control of Chronic NCD, which pursues the following general objectives: (i) to reduce the prevalence of risk factors for NCD in the general population; (ii) to reduce mortality from chronic NCD; and (iii) to improve access and quality of care, both in the detection and treatment of people at risk and affected by chronic disease. To this end, the intervention strategy for the control of chronic diseases includes three lines of action: (i) health promotion and control of NCD risk factors in the population as a whole population approach; (ii) reorientation of health services, including the integrated management of chronic diseases in the healthcare system; and (iii) surveillance of NCD and Risk Factors. The success of this strategy required, in the first place, provincial teams with training for a comprehensive approach to the problem that will contribute to sustain integrated clinical teams and deepen the development of the strategy throughout Argentina. Similarly, it was necessary to strengthen the first level of care to provide more effective detection and control of NCD, through training strategies and other incentives with the participation of various institutions. 22. Previous work under the Proteger Program (P133193) has contributed toward enhancing the care for NCD. 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. To this end, the operation supported: (i) the implementation of systematic assessment tools focusing on the delivery of NCD services in primary healthcare facilities with financial incentives provided under a result base mechanism; (ii) the development of provincial plans for an integrated approach toward NCD detection and treatment and underlying risk factors; and (iii) NCD training to health staff at the provincial level. These actions have resulted in 1,166 primary healthcare facilities certified for the detection and control of NCD. The supported actions contributed to the generation of organizational, cultural, and behavioral changes that require sustainability over time to achieve effective results. One of the main challenges to maintain the milestones achieved is to continue improving and expanding quality assessments to secondary level facilities and to new health dimensions such as mental health, gender and diversity perspectives, patient safety, quality management and risk management, as well as further strengthening health information systems as a precondition for high-quality care. 23. The MSN in 2019 adhered to the Strategy and Plan of Action to Improve the Quality of Care in the Delivery of Health Services 2020-2025, approved at the 57th Directing Council of PAHO. In alignment, the MSN then created the National Health Quality Plan 2021-2024 to strengthen the overall governance of the health system and develop a culture of quality and promote sustained quality improvement in the provision of comprehensive health services, which involves promoting leadership and innovation, commitment to ethical Page 95 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) values, effective communication, and permanent and proactive commitment of all individuals and agents at all levels. 24. The PforR will build directly on the Proteger Program and support further quality improvements in primary healthcare by supporting the administrative act creating the primary healthcare Quality Tool (DLR 5.1). The MSN has been working on a new tool defining the processes and standards for recognizing facilities committed to quality at primary level, to incorporate primary healthcare facilities into the National Health Quality Plan. The installed capacity and previous experiences in the application of instruments from other programs, including the previously mentioned, is being used to homogenize criteria related to the evaluation and integral performance of the facility in terms of quality and safety of the care provided. This primary healthcare tool will include requirements to comply with standards for the detection of gender violence, elements related to indigenous peoples, quality guidelines for referral and counter-referral within primary healthcare. 25. In addition, the PforR will contribute to ensuring that healthcare facilities committed to the quality agenda get recognized and receive adequate support to keep working on related goals (DLR 5.2). Specifically, this DLR will focus on supporting process measures within health facilities, such as the recognition of inpatient public health facilities as facilities committed to quality according to MSN Resolution 1744/21 (DLR 5.2). Currently, inpatient public health facilities do not have complementary quality of care units to monitor and provide support to facilities for continued quality improvement. Furthermore, the problem is worsened by weak compliance with protocols and standards, limited staff performance monitoring, and accountability and supply side gaps, such as shortages of drugs and equipment and lack of infection prevention and control. This resolution, approved in 2021, mandates that, for accreditation, the following steps must be taken: (i) the identification of a multidisciplinary team per facility and the formation of a quality committee; (ii) the completion of a self-assessment that includes 59 criteria – essential, necessary, and recommended – and be sent to the quality management through the computer system, so that it can perform the verification. According to the total criteria, the facilities are certified and an action plan with corrective and preventive actions is developed. Here this DLR will monitor the number of facilities at secondary level that have been recognized as committed to quality, including new requirements to comply with standards for climate change adaptation and disaster response, to prevent or reduce the effects of climate change on health facilities. These adaptation guidelines and standards will include specific measures to ensure facilities are able to deal with extreme heat events through effective insulation and shading, and that they are equipped to respond to wildfires with axes, fire beaters, as well as having ambulatory facilities able to deal with these threats. 26. To sustain improvements in the quality of cancer care, the PforR will support the accreditation of Mammography Centers in quality (see the IRI). Improving screening requires substantial investment and recurrent costs for necessary screening equipment (i.e., mammography machines) as well as its proper maintenance and use. In the case of mammographies, correct diagnoses depend on several factors: breast density, training of the reader, and quality of the equipment. In 2001, a Guide of Basic Guidelines for Quality Control in Mammography82 was approved and incorporated to the National Program for Quality Assurance in Medical Care; it was elaborated by the Commission of Diagnostic Imaging (created by MSN Resolution 161/99), formed by scientific associations and entities related to diagnosis and treatment. In 2022 the INC published the Manual for the Evaluation of Quality and Safety Standards in Breast Diagnostic Services. This document and its 82 Bases for a quality assurance program (MSN Resolution 233/2001 and Annexes) Page 96 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) recommendations related to all the essential components for mammography screening provide the technical guidance and basis for the actions required to achieve the IRI. 27. Furthermore, and to meassure improvements in quality, DLI 4 will support the timely treatment of breast cancer and its appropriate registration, since breast cancer is the first cause of death by tumors in women in Argentina52. While early detection is critical for improving breast cancer outcomes and survival, once diagnosed, the care of people with cancer requires moving from a reactive model, centered on the disease, to a proactive and planned model, centered on the person and their context. To this end, DLI 4 will incentivize the increase in the percentage of women with diagnosed breast cancer that receives timely treatment and is registered in MSN systems; DLI 4 is related to healthcare services and a tracer indicator included under the benefit package of the Sumar Program. 28. The PforR will support improvements in data management and utilization. The Government is strongly committed to strengthening digitized data collection in the sector. Having reliable information is seen as a foundation for increased accountability and helps ensure decision-making becomes more evidence-based. Clinical information system is one of the pillars for continuity and coordination of services. A well-functioning health information system is one that ensures the production, analysis, dissemination, and use of reliable and timely information on health determinants, health system performance, and health status. Timely information about individual patients and populations of people with NCD is an important feature of effective programs, linking all members of the network, including information on planning and processes for evaluation and monitoring, as well as clinical decision support tools that aggregate data to guide continuous improvement in the quality of care. However, Argentina’s health information system within the Argentine public networks is particularly weakened by fragmentation. This lack of coordination and continuity, often results in ineffective care, including delays in receiving results, discontinuation of treatments and medical errors; as well as gaps and duplications that generate waste. 29. The NIHP builds on health information systems as a key enabling factor to facilitate the integration and continuation of care, in an efficient and secure manner. The integration and continuation of care is facilitated when patients and health professionals can share information with other providers, and when patients’ medical records can be transferred electronically between health facilities. Electronical Medical Record (EMR) allows health professionals to consult, manage, and record all events relevant to the contact of a patient with the health system. EMRs can help, on one hand, to deliver better quality of care by reducing medical errors, supporting the continuation of treatment and, on the other hand, to create efficiency gains, by reducing duplicate testing, over- prescription of medicines and streamline administration, among others. 30. A successful health information strategy typically involves setting national standards for sharing EMR and other clinical documents across different healthcare facilities. In a decentralized healthcare system, as it is the case of Argentina, decisions are taken at a subnational level, including those related to the health information systems. By setting interoperability standards, each information health system deployed in the country can speak to another. In fact, interoperability is defined as the ability of two or more systems to exchange information and to make use of exchanged information. It is an essential pre-condition to share information across healthcare facilities. The standards83 provide the mechanism to send and receive clinical data among different health 83 See https://www.argentina.gob.ar/sites/default/files/infoleg/RES680.pdf Page 97 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) information systems, regardless of the technical characteristics, infrastructure technologies, development languages, types of databases, etc. 31. The National Digital Health Strategy (2018-2024) implemented by the MSN seeks to set national standards and to achieve interoperable information systems. Through the National Digital Health Network (Red Nacional de Salud Digital), the government aims at ensuring the interoperability of the Health Information Systems throughout the country. The Network is made up of “nodes”, which represent independent health information systems, used at provincial, municipal or health facilities level. Each “node” has a Patient Identification System and its own data repository.84 Through this network, clinical information can be shared between the different levels of care and jurisdictions.85 The objective is to ensure that both, the EMRs of the patient's history and those records from the national vaccination, epidemiological surveillance, and statistical programs, register timely, accurate and complete data and that these data are shared through interoperability standards, simplifying information flows.86 32. Through the implementation of interoperability standards, the information shared across health providers is secure and in compliance with the data privacy. In the case of data from EMRs, the standards for sharing are based on the International Patient Summary (IPS) and HL7 FHIR. The IPS is an extract from the EMR, including essential clinical information such as basic patient’s data (name, date of birth, gender), health conditions, medication summary, allergies, and problem list. The implementation of IPS will enable a patient to receive more continuous and better-informed care across healthcare settings and jurisdictions. Results Area 4. Improved efficiency through coordination and integration of the health subsystems. 33. The PforR will support improvements in the efficiency of health expenditure through the strengthening of centralized procurement arrangements to reduce the cost of drugs (DLI 6). Challenges related to the improvement and strengthening of pharmaceutical policies and to the growth in judicial claims related to health remain and impose a strain on the overall efficiency of the sector. Technological advances are a key driver of health expenditure growth, involving both diagnostics and treatments, which in turn include pharmacological and non-pharmacological interventions.87 Argentina has been impacted by inflation significantly driving, at least partly, the 25 and 37 percent growth in expenditures for medicines in 2021 and 2022, respectively. As for January 2023, the interannual variation in prices of medicines rose to 88.4 percent for the Total Basket of observed prices. 88 High-Cost medicines account for an increasing share of expenditures in medicines. In 2010, these drugs represented eight percent of total spending on medicines, while today that proportion has increased to 62 percent, according to industry estimates.89 34. Lowering prices of medicines, especially innovative and expensive medicines,90 is possible through a variety of measures which Argentina is using: Due to economies of scale, pooled and collaborative procurement 84 For more details see: https://www.argentina.gob.ar/salud/digital/red. 85 Boletín Oficial. MSN Resolution 189/2018 86 Decree 802/18 87 Rozmarinová, J. 2020 Health Technology Assessment. Literature Review. Current Trends in Public Sector Research. Proceedings of the 24th International Conference https://doi.org/10.5817/CZ.MUNI.P210-9646-2020-12 88 DES 2023. SEGUIMIENTO DE PRECIOS DE MEDICAMENTOS EN EL MES DE ENERO 2023 - INFORME INMEDIATO - Dirección de Economía de la Salud. https://www.argentina.gob.ar/sites/default/files/2023/01/informe_variac_medicam_enero_2023-_622023.pdf 89 Observatorio de Costos de la Salud de la Unión Argentina de Salud (UAS) 2022. https://uas.com.ar/advierten-por-fuertes-subas-en- medicamentos-de-alto-costo/ 90 García-Goñi, M 2022, “Rationalizing Pharmaceutical Spending,” IMF Working Papers 2022/190 (Washington: International Monetary Fund). Page 98 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) at the national (or even supranational) level produces savings (DLI 6). Regarding innovative and expensive medicines protected by patents, many countries use external reference prices and health technology assessment for setting their price and reimbursement. An alternative for setting prices for innovative pharmaceutical products is through Managed-Entry Agreements also known as Risk-Sharing Agreements. These are agreements between the payer and the manufacturer that can vary in complexity. This may involve simple discounts and price-volume agreements in a financial-based scheme. Or it can be related to clinical outcomes, such as performance-based schemes that establish a direct relationship between the final price and the observed health outcome. The Managed-Entry Agreements are particularly relevant when drugs obtain marketing authorization for narrowly defined patient populations and early-stage disease, where fewer patients may be available for recruitment and generating mature outcomes can be prohibitively long. In these cases, Real-World Evidence (RWE) is necessary to fill this gap by complementing and supplementing clinical trial evidence, as well as reducing health technology assessment body uncertainties that can delay reimbursement decisions.91 Argentina has started to successfully develop a Risk-Sharing Agreement and is seeking to apply it to additional high-priority medicines 35. The PforR will also support improvements in the equitable access to quality healthcare as well as transparency and accountability of resource allocation through the adoption of an explicit costed health benefits package applicable for the different health sectors, based on care protocols and costed lines of care, with defined mechanisms for updating and incorporating technologies (DLI 7). A well-defined health benefits package helps ensure that the entire population has access to a similar set of essential healthcare services regardless of their socioeconomic status or ability to pay and thereby promotes health equity by reducing disparities in access to care. The proposed PAISS benefit package provides a clear definition of the services that are covered. Lines of care have been selected based on four criteria (population’s burden of disease, equity in access, potential benefits, and severity of disease) and, for each line care to be included in the PAISS, every healthcare service is being subjected to a cost-effectiveness evaluation. This approach helps policymakers allocate resources more efficiently and effectively according to a transparent process, thereby creating accountability. An explicit health benefits package also supports quality improvement efforts by defining the scope of services that should be provided to patients according to evidence-based criteria. 36. Currently, there is no such explicit general benefit package in Argentina, but the PAISS has the potential of aligning the public sector and the social security sector in terms of their service delivery structure. While there is a Mandatory Medical Program92 supervised by the MSN, it just serves as a regulatory framework established by the Federal Government to ensure that all Obras Sociales offer a minimum package of medical services and benefits to their members, but it does not apply to the public sector. With respect to the public sector, the provincial ministries primarily in charge of service provision and the MSN provide and finance – with different degrees of coverage and with few explicit prioritization mechanisms (such as under Sumar Program), healthcare services, medicines and supplies through different Directorates, Programs, or Plans. As a result, the selection of what to finance does not always follow clear prioritization criteria and is not agreed upon by the different decision-makers. This situation leads to greater efforts and little efficiency in the management of resources. 91 IQVIA 2022 Impact of RWE on health technology assessment Decision-making. Report https://www.iqvia.com/insights/the-iqvia- institute/reports/impact-of-rwe-on-hta-decision-making 92 The Mandatory Medical Program was first introduced in 1993 and has since been updated several times to reflect changes in medical practice and advances in technology. It includes a list of medical procedures, tests, treatments, and medications that must be covered by all health insurance plans in Argentina, as well as guidelines for their use and administration. Page 99 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 37. The proposed PAISS also builds on the experience of the Sumar Program. The public health sector already has experiences and tools that tend to create a benefit package for the public system. One of these is the Sumar Program's Health Services Plan, which specifies which health services are prioritized according to the needs of the beneficiary population identified on the basis of an analysis of national epidemiological profiles. 38. The PforR will also support advances towards a fully digital medical prescription system which reduces costs from duplicated or erroneous prescriptions as well as prescriptions not promoting the use of cheaper generic drugs. (DLI 8). Paper-based systems of prescribing and dispensing medications are prone to widespread problems with safety and efficiency. In a study for the US system, the shift from paper-based to electronic prescribing systems had been estimated to prevent more than two million adverse drug events annually and thereby create savings in healthcare costs.93 In addition, e-prescribing improves workflows within the healthcare system and allows for the easier detection of medication duplication in prescription when different doctors prescribe the same medication and alerting prescribers to cheaper generic alternatives. With beneficial impacts for overall quality of care, electronic prescriptions can be easily tracked and managed by healthcare providers, which can help to improve medication adherence and reduce the likelihood of medication-related complications. In a fragmented healthcare system, like the Argentine one, these benefits from improved coordination are particularly important. 39. Advancing in climate change adaptation and mitigation measures is imperative for the Argentine health system to reduce the incidence and severity of climate-related illnesses and thereby proactively manage the future burden on the system (DLI 9). The focus on climate change adaptation and mitigation is a new emerging priority for health policy makers, because climate change has significant impacts on human health. Defining a strategy to deal with this new yet increasingly urgent context is the first crucial step in ensuring a comprehensive sectorial response. DLR 9.1 (Administrative act approving the Health and Climate Change Strategy), DLR 9.2 (Number of provinces with provincial health and climate change plans approved) lay the strategic basis at the national and subnational levels for this comprehensive response. 93Porterfield A, Engelbert K, Coustasse A. Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting. Perspect Health Inf Manag. 2014 Apr 1;11(Spring):1g. PMID: 24808808; PMCID: PMC3995494. Page 100 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Table A3.2. Sequencing of PforR supported Activities Prior Y1 Y2 Y3 END RA 1 Consolidated and institutionalized health financing mechanism Administrative act for the integrated transfer mechanism from the Nation to the Provinces and its related Annexes approved (Decree, Resolution) Design a National Fund for High-Complexity Diseases based on the National Fund for Equity in Health (FONES) Pre-condition for equitable and Allocate national budget to finance National Integrated Health Plan (NIHP) including the financial effective Coverage integrated capitation transfers to provinces to purchase an Essential Health Benefit Package Sign agreements with provinces to implement National Integrated Health Plan (NIHP) including signed sections that pertain to the Program (mechanisms for health financing) RA 2 Increased Equitable and Effective Coverage to health services Transfer capitation payments to provinces for purchasing an Essential Health Benefit Package Improved Equitable and Effective Manage the National Fund for High-Complexity Diseases Coverage of health services for the Manage the administrative and incentive mechanism from the Nation to provinces, and compile population without formal health the indicators of increased effective coverage (result based financing schemes) insurance RA 3 Improvements in the Quality and Integration of Care in the Public Sector Design an evaluation tool for quality standards for Primary Healthcare certification which includes climate standards Evaluate and follow up of healthcare facilities according to quality standards defined in each quality tool (including climate standards): primary healthcare facilities, Inpatient Facilities, Improved Equitable and Effective Mammograms Coverage of health services for the Creation of the pediatric oncology network at the National level population without formal health Geo-reference teams for gender-based violence (GBV) at the provincial level insurance Design, approve, and promote regulatory actions to protect population against risk factors for Non-communicable diseases (NCD) Implement standards for sharing clinical information Monitor citizen grievance mechanisms RA 4 Improved efficiency through coordination and integration of health subsystems Conduct integral analysis and revision of the list of essential medicines Implement efficient purchasing mechanisms for essential drugs efficient purchasing mechanisms for essential drugs of new list Design and implement a Health Benefit Package (HBP) for the entire health system Improved Efficiency of the health Design a digital prescription strategy system Implement a digital prescription strategy Implement a digitalized pharmaceutical inventory Design and approve the National Strategy for Health and Climate Change Implement Adaptation and Mitigation strategies for Climate Change Page 101 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) B. Institutional arrangements and Monitoring & Evaluation 40. The Program will be implemented by the MSN which will provide overall oversight of Program execution. The MSN will be responsible for high level coordination with the other actors involved in Program implementation. The MSN is responsible for overall stewardship of the health system; as such, it develops norms, standards and guidelines, and provides technical assistance for their implementation. Table A3.3 below details the roles and responsibilities of each involved agency linked to the achivement of the DLIs. 41. The Secretariat of Equity in Health (SES) within the MSN will be the technical and operational coordination unit for the Program. The National Directorate of Provincial Systems Strengthening (DNFSP) under the SES will be responsible for coordinating the Program activities through the MSN’s different Secreataries such as Quality, and Service Delivery, and its Directions and the National Cancer Institute (INC). To this end, the DNFSP will be responsible for coordinating the collection of data to monitor indicator performance. DNFSP is staffed with a National Director who will be the Program Coordinator, and with technical staff members who have the adequate capacity to support the Program implementation. The implementation of the PforR will also build on the successful implementation arrangements under the Sumar and Proteger programs previously supported by the Bank, as the Project Coordination Team (PCT) that was established within the MSN for the purpose of supporting the Sumar and Proteger programs is further institutionalized. 42. The Secretariat of Administrative Management (SGA) within the MSN, will be responsible for budget management, procurement and financial management, all this in accordance with Decree 945/2017 articles 1 and 2. Specifically, the General Directorate of Projects with External Financing (DGPFE), under the SGA, will be in charge for reporting on the financial statements; reporting DLIs; coordinating the external verification with the National Internal Audit Agency (SIGEN) and for submitting the disbursement requests to the World Bank. 43. Within the MSN Program‐relevant departments, as well as in each of the other participating entities, a team of one or two key staff members will be designated as focal points. They will be responsible for supervising Program implementation according to their areas of competence and ensuring timely coordination to achieve the DLI targets. They will work in close collaboration with DNFSP. The Provinces are responsible for the provision of the healthcare to the Program’s population. Participation by provinces will be governed by the corresponding section of the Participation Agreement pertaining to the Program signed between each province (represented by the Minister of Health) and the MSN, to cover the duration of the Program period. These agreements will cover the requirements related to the Program including, inter alia, the, technical, financial, administrative, fiduciary, and environtmental and social aspects of provincial participation in the program. These agreements are linked with DLR 1.3, as will be needed for transferring funds under the PforR result framework to the participating province. 44. The Government Supreme Auditing Institution (AGN) will be responsible for conducting annual financial audits to the MSN; covering the Program transfers made by the MSN to the participating Provinces. 45. The SIGEN, through a dedicated team at the central level, will be responsible for the verification of DLIs, according to Terms of Reference for the Verification Agency acceptable to the Bank and to be included in the Program Operations Manual (POM). Specialized staff managed by SIGEN’s central level and separated from the Internal Audit Unit at the MSN will perform tasks and validations required for DLIs verification specified in the Terms of Reference agreed with the Bank. SIGEN has the capacity to provide independent verification for the DLIs and to ensure credible verification of the achievement of the DLRs and it was selected in acceptance of the Bank. Page 102 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Table A3.3. Roles and Responsibilities of Entities Linked to Each DLI DLI 1. Consolidated and institutionalized health financing mechanisms MSN: through the SGA, will: (i) issuance a norm to establish results-based transfer mechanism to MSP, (ii) create and maintain a budget line for these transfers; (iii) prepare and sign Umbrella Agreements with MSP to enforce the compliance of institutional arrangements to implement the PforR; and (iv) coordinate with the DNFSP under the SES the technical issues of the PforR and the signing of agreements with the MSP. MSP will sign Umbrella Agreements with MSN and display institutional arrangements to implement the PforR. DLI 2. Population with basic effective coverage MSN, through the DNFSP under the SES, will: (i) collect data to monitor performance and reporting at individual level; and (ii) coordinate activities with MSP to improve outcomes and quality standards. MSP will: (i) collect and present data to MSN to report progress in basic effective coverage at individual level; (ii) finance the provision of a health benefit package with quality standards; and (iii) implement activities to improve outcomes. Healthcare facilities will provide health services to population with public health insurance with quality protocols and standards. DLI 3. Coverage of children with MMR vaccination registered at individual level MSN, through the Secretariat of Health Access will: (i) collect data at individual level from the Federal Vaccination Registry (NOMIVAC) to monitor performance; and (ii) coordinate activities and reporting of immunizations campaigns. MSP will: (i) collect and present data to MSN to report progress in MMR vaccination registered at individual level; and (ii) finance the immunization campaign. Healthcare facilities will provide MMR vaccination and register it at individual level. DLI 4. Timely breast cancer treatment and registration MSN, through INC, will: (i) implement activities to strengthen information systems and improve registration in healthcare facilities; and (ii) in coordination with the DNFSP collect data to monitor performance and reporting. MSP will: (i) collect and present data to INC to show progress in breast cancer screening; (ii) finance the provision of breast cancer screening; and (iii) implement activities promoted by INC to improve breast cancer screening registration. Healthcare facilities will provide and register breast cancer screening. DLI 5. Certification of Healthcare Facilities for Quality and Climate Standards MSN: The MSN, through the Secretariat of Health Quality and SES, will: (i) design and implement quality and climate adaptation evaluation tools; (ii) coordinate with MSP the implementation of these tools; (iii) provide technical assistance to MSP; (iv) analyze the information provided by healthcare facilities; (v) assign healthcare facilities to quality categories according to results obtained in the implementation of the evaluation tools; and (vi) coordinate with the DNFSP data collection and reporting. For the pediatric oncology network, the MSN through the INC under the Secretariat of Health Access, will issuance a norm to establish the Coordinating Center and its responsibilities to manage the network. Technical assistance to prepare the norm will be provided by the SES and the INC. MSP will: (i) coordinate the implementation of quality and climate adaptation evaluation tools; (ii) provide information to the MSN; and (iii) provide technical assistance to healthcare facilities. Healthcare facilities will implement quality and climate adaptation evaluation tools DLI 6. Savings in the purchase of essential medicines MSN, through the SGA and the Health Access Secretary, will design a methodology to support the integral analysis and revision of the list of essential medicines being purchased at central level. Then an administrative act will be issuance which will establish the new essential medicines to be purchased. Savings will be measured relative to the retail price at Page 103 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) the time of award. DLI 7 Argentine Integrated Health Services Plan (PAISS) MSN will issuance the administrative act of institutionalization of the PAISS with a benefit package for priorities lines of care and a roadmap for its implementation. The MSN will provide the technical design of the benefit package and the implementation strategy. DLI 8. Administrative Act for Digital Prescription MSN will regulate the implementation of digital prescriptions according to Law 27,553 which systematizes definitions, requirements, responsibilities, and details, on digital prescription and of the platforms regulated by the law DLI 9. Adaptation and mitigation strategies for climate change MSN: The Climate Change Program under the MSN will: (i) provide technical assistance to MSP to implement Provincial Plans for climate change adaptation and mitigation in the health sector, and (ii) coordinate activities with the Ministry of Environment, to support the implementation of the National Strategy and the issuance of an administrative act to approve the National Strategy. MSP will design and implement provincial health and climate change plans according to National guidelines. C. Results Monitoring and Evaluation 46. The results framework indicators are measured by the DLIs and the IRIs and will rely on well-developed government monitoring and reporting systems. The DLIs will be monitored and verified on the existing health management and information system at MSN; the Health Integrated Information System (SISA). The progress of process indicators related to regulatory changes or institutional process will be verified as published in the boletín oficial and in the Electronic Document Management and in the Integrated Financial Information System Internet (e-SIDIF). Data for access to health services will be built on proven robust information systems and instruments that are key for the result-based capitation payments of Sumar Program, all under the MSN’s HMIS (the SISA) and or any other replaced system, including, inter alia: (i) the Roster Management System (Sistema de Gestión de Padrones); (ii) Provincial Health Service Billing Systems; (iii) Health Service Consumption Registries and Medical Records; and (iv) the Tracer System; (v) the Screening Information System (SITAM) and the Argentina Institutional Tumor Registry (RITA), managed by the INC (both systems will be further strengthened during implementation of the Program; (vi) the NOMIVAC that records vaccinations at the individual level; (vii) the Federal Registry of Health Facilities (REFES) and Redcap (Research Electronic Data Capture). Indicators related to effective access and utilization of key health services will be disaggregated by sex. The result framework indicators will be measured on the same HMIS and will be monitored periodically. 47. The MSN’s SES, through the DNFSP, will be responsible for collecting the information required to ensure DLI compliance and for submitting it to DGPFE for SIGEN’s verification. Also, the DNFSP will ensure that technical and analytical areas of the MSN, and the MSPs, report timely progress of result framework indicators, and serve as focal point to the World Bank Group for purpose of program technical supervision. 48. Important to highlight is that all records containing personal data are stored in ARSAT’s national data center, a publicly owned company. The World Bank, through the “Argentina: strengthening data infrastructure to close the digital gap” (P178609) Project and the “Digital Inclusion and Innovation in Public Services” (P174946) Project, carried out assessments to ensure that ARSAT implements the appropriate cybersecurity standards and Page 104 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) complies with international regulations94. The high standards ensure the correct preservation of the data stored and the operation of its infrastructure. In addition, personal data privacy is regulated by laws 26,529 and 25,326. Law 25,326, the Personal Data Protection Law, also follows international standards and has been considered as granting adequate protection by the European Commission. Decree 1558 of 2001 includes regulations issued under the Personal Data Protection Law. D. Program’s Expenditure Framework 49. Total health expenditure in Argentina remained relatively stable at around ten percent of GDP between 2017 and 2020, with a maximum in 2020 of 10.84 percent and a minimum in 2019 of 10.16 percent (See Figure A3.1, below). During the period, the relationship between public sector health spending plus social security (“obras sociales”) and GDP exceeded the minimum level suggested by the WHO for public investment in health necessary to achieve universal health coverage, which is set at six percent, reaching seven percent of GDP in 2020. Figure A3.1. Health Expenditure in Argentina. Percent GDP by sector. 2017-2020 12.0% 10.8% 10.3% 10.3% 10.2% 10.0% 3.7% 3.6% 4.2% 4.0% 8.0% 6.0% 3.9% 4.0% 3.7% 4.0% 3.6% 2.0% 2.7% 2.5% 2.5% 3.2% 0.0% 2017 2018 2019 2020 Public expenditure Social Security expenditure Private expenditure Total Source: MSN, National Institute of Statistics and Censuses (INDEC), Ministry of Economy. 50. Within total spending, the largest proportion corresponds to social security, which represented in average 36.4 percent of total spending. This proportion fell slightly over the 2017-2020 period as shown in Figure A3.2, below. Private spending, compensated for this fall in 2018 by increasing its relative weight and then, in 2020, registering its lowest contribution (34.5 percent). Public sector financing remained stable at around 24-26 percent, while in 2020 it registered a significant increase reaching 29.2 percent. Within the public sector, the provinces are the ones with the highest relative proportion of spending (between 65 and 68 percent according to MSN figures). This is due to the Argentine federal organization, where the provinces are autonomous and maintain all the functions not explicitly delegated to the Federal Government, among them the healthcare of its population, which is preserved as an original competence of the provinces by constitutional mandate. Within the expenditure of the social security sector, the national institutions (“obras sociales nacionales” including the National Institute of Social Services for Retirees and Pensioners (INSSJyP/PAMI)) are the ones that contribute the most to total 94 Assesments had been carried out at Projects’ appraisal; November 2022 and March 2021, respectively. Page 105 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) expenditure with around 75 percent of the spending in that sector. These shares remained relatively stable between 2017 and 2020.. Figure A3.2. Total Health Spending by Source of Financing. 2017-2020. 100.0% 80.0% 35.0% 39.2% 34.5% 41.0% 60.0% 38.5% 36.3% 40.0% 34.5% 36.4% 20.0% 26.5% 24.5% 24.4% 29.2% 0.0% 2017 2018 2019 2020 Public expenditure Social Security expenditure Private expenditure Source: MSN, Ministry of Economy. 51. Considering spending in local currency (ARS) and in constant values (2017 prices), the figures show a drop in health spending throughout the entire series that represents eight percent. Total health spending goes from ARS1,094 billion in 2017 to $1,007 billion in 2020 at constant 2017 values. However, a significant increase in public spending is observed, while social security spending and private recorded a drop between 2017 and 2020. Considering per capita spending, similar conclusions are obtained. Although spending increases in current terms, when it is expressed in constant 2017 values, a reduction of 11 percent can be seen during the 2017-2020 period, since monthly spending per capita goes from ARS2,070 in 2017 to AR $1,848 in 2020, with a single increase in real terms between 2017 and 2018 of 2.5 percent. 52. The increase in prices in the health sector has been the main cause of the loss in real terms of health spending. As seen in Figure A3.3, between 2017-2020 the rate of increase was higher in the prices of medicinal products, drugs, and medical equipment. While in the last months of 2021 and the first half of 2022 a pronounced increase in expenses related to private insurance is observed, including the value of voluntary contributions to private insurance companies (“prepagas”). Page 106 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Figure A3.3. Health-related prices in Argentina. Inter-annual (percent). 2017-2022. 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Dec-17 Sep-18 Dec-18 Sep-19 Dec-19 Sep-20 Dec-20 Sep-21 Dec-21 Mar-18 Jun-18 Mar-19 Jun-19 Mar-20 Jun-20 Mar-21 Jun-21 Mar-22 Jun-22 National CPI - Health Total National CPI - Medicinal products, drugs and equipment for health National CPI - Private Health Insurance expenditures Source: INDEC. 53. The MSN implemented different interventions to expand the response capacity of the health system as a whole during the COVID-19 pandemic, and particularly the operational capacity of the provinces, complementing the health spending made by the jurisdictions with additional resources and transfers. There was an expansion of health spending through increases both in the budget of the MSN central administration and the decentralized bodies that work under its orbit. In this way, not only the national programs were strengthened (such as Sumar, Proteger, Redes, Remediar and Vaccine Program), but also the hospitals categorized as SAMIC (Community Medical Care System), through transfers from the central level. It is worth clarifying that these hospitals are financed jointly with the municipality and/or the province where the facility is located. As a result, the budget of the MSN central administration was increased by almost ARS69,400 million, ending 2020 with a budget credit 165 percent higher than the initial one, according to MSN figures. 54. Expenditure Framework. The MSN has assigned initial budget to each of the 11 strategic lines of the NIHP, which include 14 programs and 29 activities or budget lines. The total budget for NIHP is US$920 million in 2023, and US$3,072 million between 2023 and 2025. This PforR is going to support 10 of these programs and 14 activities over three years (2023-2025), based on their scope and volume of resources, as shown in Table A3.4. The total budget allocated to these activities over these three years is estimated at US$1,713 million or 56 percent of the NIHP. The PforR supported activities include the following expenditure categories between 2023 and 2025 as shown in Table A3.5: (i) human resources for US$208 million, or 12 percent of the total expenditure framework; (ii) goods, such as vaccines and drugs, for US$1,163 million (68 percent); (iii) services, such as logistics operations for US$85 million (5 percent); (iv) goods such as information technology (IT) equipment and medical equipment for US$6 million (0.3 percent); and (v) results-based transfers to provinces for US$251 million (15 percent). Expenditures associated with infrastructure are not included in the scope of the expenditure framework. These selected budget programs will not receive cofinancing by other multilateral development institutions, but from national funds. Page 107 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Table A3.4. Expenditure Framework Budget (US$ Million) Total Budget Program* Budget Activity* 2023-2025 01. Central Activities 03 - Administrative Support Activities 170 14 - Integration of Health Coverage 1 16. Support for the Development of Healthcare 49 - Implementation of Health Information 2 Systems 20. Prevention and Control of Communicable and 43 - Standards, Supply and Supervision of 937 Vaccine-preventable Diseases Vaccinations 21. Planning, Control, Regulation, Studies, Research 08 - Quality Assurance of Healthcare 2 and Oversight of Health Policy 22. Response to HIV, STIs, Viral Hepatitis, 46 - Prevention and Control of Viral Hepatitis 53 Tuberculosis and Leprosy 47 - Prevention and Control of Tuberculosis 6 24. Comprehensive Approach to Noncommunicable 47 - Coordination, Prevention and Control of 6 Diseases and their Risk Factors Noncommunicable Diseases 6 - Prevention of Adolescent Pregnancy 32 25. Development of Sexual Health and Responsible 41 - Development of Sexual Health and Procreation 87 Responsible Procreation 45 - Provision of Essential Drugs, Supplies and 110 29. Access to Drugs, Supplies and Technology Technology 46 - Bank of Oncological and Special Drugs 51 42 - Supporting Effective Universal Health 47. Development of Public Health Insurance 246 Coverage in Argentina (Sumar Program) 50. Actions for Gender Identity 01 - Actions for Gender Identity 11 Total 1,713 * Budget programs and activities are according to 2023 Budget Law denomination for each budget line. Table A3.5. Estimated Three-Year Budget – US$ Million NIHP Expenditure Framework 2023 2024 2025 Total 2023 2024 2025 Total Human resources 78 84 100 262 62 67 79 208 Consumption goods 566 605 719 1,890 338 377 448 1,163 Services 58 62 74 194 14 33 39 85 Equipment goods 52 56 67 175 2 2 2 6 Transfers 165 176 209 550 2 114 135 251 Total 920 984 1,169 3,072 417 592 704 1,713 Source: MSN Budget Estimations based on 2023 Approved Budget Law for the Central Administration. 55. The prioritized NIHP to be supported by the PforR is aligned with the RAs and represents an adequate portion of the total assigned budget and is sustainable. Furthermore, the programs and activities included correspond to core functions of the MSN and have been historically well executed by the MSN over the years, as Page 108 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Figure A3.4 shows the percentage of MSN budget execution with an average of 95.9 percent in the period 2014- 2021. Also, there was a high level of execution for the main program budget lines included in the expenditure framework. Vaccination program and Essential Drugs program had an average of 97.9 percent and 93.2 percent, respectively. The transfers to subnational (provinces) jurisdictions have had high levels of budget execution over almost two decades related mainly to the funds transferred through Sumar Program, which had an average budget execution rate of 93.7 percent over the period 2014-2021. These figures are evidence that the supported lines of programs have been well executed over the years and that their financing is sustainable. Figure A3.4. MSN Budget Execution Rate. 2014-2021. 120.0% 110.0% 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 2014 2015 2016 2017 2018 2019 2020 2021 Vaccination Essential Drugs Sumar Program Total MSN Note: Figures for National Administration without Applications, Financial Sources, Contributions and Figurative Expenses. Source: Integrated Financial Information System, Ministry of Economy, retrieved on May 1, 2023. E. Economic Justification of the Program 56. Improvements in basic effective coverage for the otherwise uninsured population and a better integration of the national health system will yield direct economic benefits through increased efficiency of health spending and improved population health status (measured by a reduction in premature deaths and disability-adjusted life years (DALYs) from better access to and quality of primary care). In addition, spillover effects from a strengthened purchasing function for health services can be expected to generate substantial benefits across the health system. For a conservative estimation of the economic benefits, the analysis considers only two benefits: (i) productivity gains resulting from improved health outcomes, represented, for instance, by reduced maternal and infant mortality rates, as well as reduced morbidity rates related to the prioritized lines of care, and (ii) cost savings from the purchase of medicines. Benefits from improvements in information systems or from climate change-related interventions are not accounted for in the economic analysis. 57. The Program supports a set of strategic guidelines and public health activities with a high impact on the diseases burden of the population exclusively covered by the public sector. The Program will provide support to a set of strategic lines that the MSN has previously been implementing through the Sumar and Proteger Programs and that are anchored in the PAISS and the National Quality Plan. It is expected that these interventions will Page 109 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) continue to generate significant positive impacts in terms of the health outcomes of the target population and the quality of healthcare services. 58. The economic analysis estimates the costs and benefits of the Program by focusing on the medium and long-term benefits, in particular the returns to improved population health status and reduced pharmaceutical expenditure. These two analyses are then combined to calculate a single net present value of the proposed investment. Costs are calculated in US dollars and health benefits are estimated in terms of DALYs. The analysis draws on an extensive review of data from Argentina and the international literature. It builds on several assumptions from economic analyses conducted for previous World Bank projects in the Argentine health sector. 59. The monetary value of the expected health gains generated by the Program is modelled by estimating the potential impact of the Program’s activities on the burden of disease, in particular from chronic diseases. The interventions of the Program (i.e., services financed by the Sumar program under the prioritized lines of care) will help averting DALYs. In the absence of the Program (i.e., the counterfactual scenario for the analysis), the DALYs associated with these priority lines of care supported by the Sumar program will follow a different trajectory and increase more over time. The cost and benefits of the Program are calculated for three scenarios (baseline, lower impact and higher impact). The assumptions used in the cost-benefit analysis are summarized in Table A3.6. Main Parameters of the Analysis (i) Temporal Horizon. Program disbursements will take place from 2023 through 2026, whereas the long- term benefits of the Program accrue over a period of ten years. (ii) Discount Rates. The analysis uses a four percent real discount rate. Under the sensitivity analysis, higher discount rates (6 percent, 12 percent) are used to calculate the Net Present Value and the Internal Rate of Return (IRR). (iii) Beneficiary Coverage Rate. The economic outcome of the Program will depend especially on the evolution of beneficiaries with basic effective coverage and the health effectiveness of the prioritized interventions for the population groups selected. The coverage of beneficiaries is expected to increase over time according to the projections agreed upon with the Government team and also used for the corresponding DLI (see Table A3.7). (iv) Impact. The health impact of the Program is modelled through the reduction in the target population’s burden of disease which in turn is translated into an aversion of premature deaths and DALYs. The disease burden is calculated from official 2019 mortality data by sex and age for selected causes. The estimated reductions under different scenarios are presented in Table A3.6. (v) Productivity Gains. To estimate the productivity gains from improvements in health status, a monetary benefit is assigned to each avoided Year of Life Lost (YLL) due to premature mortality. Each YLL is equivalent to the average annual per capita income of the country (using the starting value of US$8,548 for April 2023 plus a growth rate of one percent per year). Each avoided year lost due to disability is valued at 70 percent of that average per capita income as an approximate measure of the loss of income of a person with disabilities.95 (vi) Program Costs: The costs included in the analysis account for both the resources made available by the World Bank and by the Government to include the total cost of the program being implemented. The financial contribution of the PforR to the Government program is US$300 million. 95 In the US, workers with a disability earn 87 cents for every dollar earned by those with no disability (US Census Bureau). Page 110 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Table A3.6. Benefits under Different Scenarios Type of Benefits Baseline Scenario High-Impact Scenario Low-Impact Scenario Increase access to Increase access to and Increase access to and and effectiveness of effectiveness of primary effectiveness of primary primary care: 8.5 care: 10 percent overall Benefits from reductions in care: 12.5 percent overall percent overall reduction in DALYs DALYs reduction in DALYs related reduction in DALYs related to disease to disease burden in the related to disease burden in the target target population burden in the target population population 25 percent reduction in 20 percent reduction 30 percent reduction in Pharmaceutical savings from Government spending in Government Government spending on centralized procurement on selected spending on selected selected pharmaceuticals pharmaceuticals96 pharmaceuticals Source: World Bank Estimates. 60. Table A3.7 shows annual estimations of the health impact of the Program, taking into account the entire target population. The health impact is affected by the level of enrollment achieved in each Program implementation year. Table A3.7. Health Impact Estimates 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 Enrolled Population with 7,0 7,3 7,7 8,0 8,0 8,0 8,0 8,0 8,0 8,0 effective coverage (in millions) YLLs due to premature deaths 2.036 2.077 2.127 2.188 2.264 2.357 2.475 2.623 2.811 3.052 avoided Year Lost due to 5.837 5.954 6.096 6.272 6.489 6.758 7.094 7.518 8.057 8.749 Disability avoided DALYs gained 7.873 8.030 8.223 8.460 8.752 9.115 9.569 10.140 10.867 11.802 Source: World Bank Estimates based on Global Burden of Disease 2020, Institute for Health Metrics and Evaluation. 61. Table A3.8 presents the results of the economic analysis. Under the baseline scenario, the NPV of the Program is US$265.4 million and the IRR is 31.6 percent. For the scenario analysis that considered a higher and lower impact of the program interventions, the IRR ranged from 24.4 percent (low-impact scenario) to 42.9 percent (high-impact scenario), while the NPV ranged from US$196.6 million to US$370.7 million. 96 Estimated to account for about 40 percent of Government spending on pharmaceuticals, to start in 2024. Page 111 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Table A3.8. Summary of Estimated Costs and Benefits in Baseline Scenario In US$ million, discounted at four percent Net Present Value Benefits Net Present Value Cost savings Net Present Year Project Costs Productivity from the Value gain purchase of medicines 2023 67.3 0.0 0.0 -67.3 2024 64.7 49.8 9.1 -5.7 2025 62.2 49.6 8.8 -3.9 2026 76.9 49.5 8.4 -19.0 2027 49.8 8.1 57.9 2028 50.3 7.8 58.1 2029 51.3 7.5 58.8 2030 52.8 7.2 60.0 2031 55.0 6.9 61.9 2032 58.0 6,7 64.6 Sub total 271.2 466.0 70.6 265.4 IRR 31.6 percent Source: World Bank estimates. 62. Finally, a sensitivity exercise was carried out with two alternative discount rates (6 percent and 12 percent, respectively). While the Net Present Value as a measure of the economic profitability of the Program decreases, it remains significantly positive (i.e., with a discount rate of 12 percent, the Net Present Value is US$123.3 million). The results stress the economic profitability and viability of the PforR. Table A3.9. Sensitivity Analysis under the Baseline Scenario ARS210 = US$1 4 percent 6 percent 12 percent Net present value, US$ million 265.4 220.2 123.3 IRR 31.6 percent Source: World Bank estimates. Disbursement Arrangements 63. Disbursement of Bank loan proceeds will be made at the request of the Borrower upon achievement of DLRs. Some DLRs (see DLR matrix – Annex 2) are scalable, thus allowing for disbursements to be proportional to the progress towards achieving the targeted DLR value. Other DLRs are not scalable, as the indicators relate to actions that are either achieved or not. Some DLRs are time-bound, to be reported and verified annually, while other DLRs are not time-bound, to be achieved anytime during the PforR implementation period; funds not disbursed in one year will be available for disbursement in subsequent years. Page 112 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 64. Five DLRs (DLR 1.1 and 1.4, DLR 5.3; DLR 8.1; DLR 9.1) are expected to be achieved prior to effectiveness, amounting US$50 million (17 percent of the Loan amount). In addition, advances of up to a cumulative 30 percent of the amount allocated to the DLIs under the Program (as a combination of the prior results and the advances) will be disbursed upon request of the Government after effectiveness (in this case US$40 million; 13 percent of the Loan amount). The advance is necessary for implementation of activities to achieve DLRs in the initial stage. The advance will be deducted from disbursements against achievement of DLRs and will be available again on a rolling basis if required. 65. The SGA will prepare technical reports to document the status of achievement of DLRs. The technical reports will be verified by the SIGEN as the selected verification agency. Upon the validation of DLRs by the SIGEN, the SGA will notify the achievement of DLRs and corresponding DLR values to the Bank, supported by the relevant evidence and documentation. Following the Bank's review of the complete documentation, including any additional information considered necessary to confirm the achievement of the DLR, the Bank will confirm the achievement and the level of Program financing proceeds available for disbursement against each DLR. 66. Disbursement requests (Withdrawal Applications) will be submitted to the Bank by the MSN using the Bank’s e-disbursement (Client Connection) system. A copy of the Bank’s official communication, confirming the DLR achievement, should be attached to the disbursement requests. MSN will copy the Ministry of Economy in the entire verification and disbursement processes. 67. Funds will be disbursed from the Bank to the MSN in US dollars based on the achieved DLRs. An amount of US$50 million of the PforR operation will be disbursed on account of the DLRs met between the date of the Program Concept Review and the date of the Legal Agreement (Prior Results). 68. As mentioned above, advances will be available under this operation. In this regard, the Bank may make an advance payment of up to US$40 million of the Program funds for one or more DLRs which still need to be achieved. Proceeds of the advance will be disbursed to an account of the MSN in the Banco de la Nación Argentina (BNA) denominated in US dollars. When DLRs are achieved, the amount of the advance is recovered from the amount due to be disbursed under such DLRs. The advanced amount recovered by the Bank is then available for additional advances (“revolving advance”). When an advance has been provided and the DLRs are achieved and verified, the advance is always recovered first. If the amount allocated to a DLR that has been achieved and verified is larger than the advance, then the Bank will disburse the amount in excess of the advance through a Reimbursement (DLR Payment). 69. The operational arrangement for the transfer of resources will be described in detail in the POM, to be approved at effectiveness. F. Evaluation of the Technical Risks 70. The Program will be implemented using existing institutions and arrangements, in particular those that have been in place to successfully implement previous World Bank Investment Project Financing (IPF) operations. To this end, the proposed PforR builds on the extensive engagement of the World Bank in the health sector in Argentina over the last 17 years, comprising both lending and technical assistance. In particular, the Program will build on the design and lessons learned from the implementation of the Sumar Program (and it predecessors) and the Proteger Project. Both projects implemented results-based transfers from the MSN to the provinces and health providers. While the Sumar Program implemented results-based financing mechanisms at the provincial and healthcare provider levels to improve effective coverage for a package of prioritized quality health services Page 113 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) for the eligible population through; the Proteger Project implemented transfer-linked indicators from the MSN to MPS for improving the readiness of public health facilities to deliver higher quality NCD-services for underserved population groups and expanding the scope of selected services. 71. While the financial management of transfers from the MSN to provinces based on achieved results as well as the calculation and verification of these results has been so far implemented based on World Bank procedures, now these processes will manage by the Government program. The PforR will support development of these capacities. In this regard and based on the experience of having supported Project implementation, the World Bank team will be able to provide technical assistance to the MSN in this important step. In addition, the support of the World Bank will help ensure that important lessons about the implementation of the results-based financing mechanisms are reflected in the design and implementation of the Program that fully relies on national systems. The Program Action Plan includes commitments regarding the strengthening of the MSN purchasing function. 72. Furthermore, the PforR builds on the World Bank analytical engagement with the MSN on issues related to quality and efficiency of the health sector. This work includes: technical assistance to institutionalize the Sumar Program while further strengthening its design through a technical assistance financed by the primary healthcare Performance Initiative (a partnership by the World Bank, the Bill and Melinda Gates Foundation, and WHO) focusing on (i) evaluating the effectiveness of different payment modalities for healthcare services from provinces to public healthcare providers with funds from the Sumar Program, and (ii) recommending possible adjustments and refinements to these payment modalities and the Monitoring and Evaluation arrangements to be implemented under the Program. Furthermore, builds on the World Bank the technical assistance on the formalization of a high complexity/high-cost network such as the pediatric cancer network, and on an ongoing technical assistance on key health stakeholders’ views on two interrelated reforms supported by the PforR; the Fund for High Cost/High Complexity Conditions and options for deciding and procuring high-price pharmaceuticals. 73. Implementation of the Program Action Plan will also contribute to development of systems and capacities in the areas of Environmental and Social management and fiduciary management. The Program Action Plan (Annex 6) includes development and implementation of a policy framework for Environmental and Social management capacity development and for financial management. Page 114 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) ANNEX 4. FIDUCIARY SYSTEMS ASSESSMENT A. Conclusions Reasonable assurance 1. The capacity and performance of the Procurement and Financial Management systems is considered adequate. With the implementation of the proposed mitigating measures and agreed actions to strengthen the systems reflected in the Program Action Plan and Program Operations Manual (POM), are considered adequate to provide reasonable assurance that the Program funds will be used for their intended purposes, with due attention to the principles of economy, efficiency, effectiveness, transparency, and accountability. Risk assessment 2. The overall fiduciary risk before mitigation measures is considered Substantial. The key fiduciary risks that underpin the Substantial risk rating and could impact the development outcomes of the Program are the following: (i) the National Ministry of Health (MSN)’s unfamiliarity with the Program for Results (PforR) Instrument, (ii) risk of inadequate planning of transfers to provinces, (iii) delays in the availability of funds for Program activities, (iv) delays in the presentation of audit reports may increase the risk of financial inaccuracies or irregularities going unaddressed for a prolonged period of time (v) potential omission in verifying firms eligibility before awarding the contract, (vi) potential delays in implementation arising from the time to prepare technical specifications and conduct technical evaluation as well as delays in obtaining the permissions to import and pay for them that could affect the procurement of specific goods, (vii) as the national legislation does not count on standards for determining qualification criteria, there is a risk of applying restrictive requirements on bidding documents and (viii) based on the sample of processes implemented under the United Nations Development Programme (UNDP) regime, it was identified that a single activity implemented through direct contracting represented 82 percent of the total amount, though when analyzing the total number of activities this method reduces to 17 percent. Although mitigation measures have been identified for all these risks at the end of the assessment, their effectiveness will only be determined during the Program's execution phase. Therefore, the fiduciary risk is still considered Substantial even after implementing the mitigation measures due to the likelihood of occurrence. The risk will be continuously monitored and reevaluated during the implementation phase. 3. To address the above risks, the proposed measures for strengthening systems capacity and implementing mitigation actions include the following: (i) The Bank’s fiduciary teams will provide close implementation support and the Borrower will prepare a POM including the recommendations arising from this fiduciary assessment; (ii) a detailed disbursement plan with clear timelines and accountabilities will be established and communicated regularly, while also providing training and capacity-building activities to provincial authorities; (iii) disbursement of funds to an MSN account held in the Banco de la Nación Argentina (BNA) denominated in US dollars; (iv) establish clear deadlines for the completion and submission of audit reports, as well as implement an effective coordination between MSN, the Government Supreme Auditing Institution (AGN) and Ministry of Economy to monitor the progress and identify any potential delays; (v) the implementing agency will be required to comply with the World Bank’s Anticorruption Guidelines (ACG) and also verify the firms eligibility before awarding a contract, which will be monitored ex post by the external auditor, and the implementing agency will have a clear reporting process for any allegations of fraud and corruption within the Program to ensure that the Bank is promptly informed, (vi) promote internal procedures to enable greater efficiency in procurement processes that will be assessed during supervision missions applying the baseline Page 115 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) performance indicators detailed in the fiduciary systems assessment to identify any bottlenecks (see Table A4.2), (vii) apply qualification requirements that enable competition (including the possibility of foreign bidders to submit a bid following the national standard bidding document) and (viii) the POM will include a requirement to apply competitive methods as the default approach whenever applicable following the national legislation and UNDP framework. Procurement exclusions 4. There are no potential high-value contracts identified under the Program. The proposed Program is not expected to finance any contract at or above prevailing Operations Procurement Review Committee (OPRC) thresholds considering the estimated activity costs under Substantial risk, which at the time are at minimum of (i) US$75 million for works; (ii) US$50 million for goods, information technology and non-consulting services; and (iii) US$20 million for consulting services. B. Scope Implementing Agency 5. The MSN will have overall responsibility for program implementation, which will be carried out through two of its Secretaries. The Program's budget, procurement, and financial management will fall under the responsibility of the Secretariat of Administrative Management (SGA), in accordance with Decree 945/2017 articles 1) and 2), respectively. The functions of coordination between programmatic areas and monitoring of PforR results will be under the responsibility of the Secretariat of Equity in Health (SES). 6. SGA is tasked with the overall implementation of Financial Management and Procurement of the Program, playing a key role in ensuring that the MSN has the resources it needs to provide quality services under the scope of the Program. The Secretariat counts on a strong financial and procurement management capacity, including the ability to prepare and manage budgets, implement procurement processes, manage accounting and financial reporting systems, and ensure compliance with legal and regulatory requirements. The following General Directorates within the SGA will be in charge of the Financial Management Arrangements of the program: the General Directorate of Projects with External Financing (DGPFE), the Directorate General of Administration and the Directorate General of Programming and Budgetary Control, headed by fifteen (15) professionals with relevant experience in each respective area of expertise. 7. The Procurement and Contracting Department within SGA has a team of 15 professionals with different levels of experience that implement procurement activities following national legislation and the applicable regulations for special procurement regimes. In consequence, SGA relies on skilled procurement staff that has been addressing the scope of the program for some years and it is not reasonable to expect any bumps on demand for more procurement work. As a technical department, SES is responsible for promoting health equity and reducing health disparities in the country and will be the technical and operational coordination unit for the Program. 8. The provincial level is responsible for the provision of healthcare to the Program's beneficiaries. It is foreseen the corresponding sections of a Participation Agreement pertaining to the Programwill be signed between each province and the MSN covering the requirements related to the Program including, inter alia, technical, financial, administrative, fiduciary, and environmental and social aspects of provincial participation in the Program. These agreements are linked to the Disbursement-Lined Resul (DLR) 1.3 for transferring funds under the PforR result framework to each participating province, which will follow the established accountability Page 116 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) mechanisms. 9. To enable a proper coordination for the Program’s implementation, a team of one or two key staff members will be designated as focal points within the MSN Program‐relevant departments, as well as in each of the other participating entities. They will be responsible for supervising Program implementation according to their areas of competence and ensuring timely coordination to achieve the Disbursement-Linked Indicators (DLIs) targets. Program Scope 10. The Program supported by the Bank is the MSN's National Integrated Health Plan (NIHP) that was created to address structural issues and improve the healthcare system in Argentina in terms of equitable access, quality of care, and efficiency. The NIHP is structured around five pillars: (i) equitable access to healthcare; (ii) quality of healthcare; (iii) efficiency; (iv) integration and health services networks; and (v) health intelligence. 11. The proposed PforR will support four out of five pillars over the three-year period of 2023-2025. The PforR´s expenditure framework includes 10 programs and 14 activities (budget lines) amounting to US$1,713 million (see Table A3.4 in Annex 3). 12. The selected budget lines include different expenditures categories: human resources, consumption goods, services, equipment goods and transfers for the period 2023 – 2025 (see Table A3.5 in Annex 3). Page 117 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 13. Based on the definition of the Program to be supported by the PforR and the implementation arrangements, the fiduciary systems assessment has focused on MSN’s fiduciary arrangements to support program implementation, including the existing mechanisms for the transfers to the Provincial level. C. Review of Public Financial Management Cycle Planning and Budgeting Adequacy of budgets 14. The Program will follow the Federal budget cycle and process in Argentina, which consists of four stages. The first stage entails the formulation of the Executive's budget proposal, followed by the second stage of congressional discussion and approval of the budget law. The third stage involves the implementation of the proposal, and the fourth stage evaluates and controls the budget execution. Figure A4.1. Federal budget cycle 15. In a nutshell, during the formulation stage, medium-term ceilings on budget aggregates and ministry/agency expenditures will be proposed by the National Budget Office (ONP) and approved by the Chief of Cabinet, and the ministries/agencies will then prepare their preliminary draft budgets on that basis. The MSN's budget unit prepares the budget documentation for review by the ONP to ensure due process in negotiating the annual budget. The MSN also plans and provides assistance to budget sector units, analyzes and adjusts proposed programs with priorities and budget availabilities, and prepares the final budget documentation. The staff of the SGA is familiar with the budget cycle and respective rules and regulations. The ONP evaluates the anteproyectos (preliminary projects) prepared by the ministries/agencies and puts together the aggregate proposal. The budget is prepared using institutional, program, functional, source of financing, and economic classifications, amongst others. 16. The ONP issues in-year budget reports, analyzing physical and financial results, and interpreting any changes from what was programmed. These reports provide comprehensive information for comparison to the approved budget by various classifications and include expenditures made for specific Programs. 17. The Federal Government's Integrated Financial Information System Internet (e-SIDIF) system provides features for commitment recording, payment processing, cash and accrual transactions, and financial statement Page 118 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) preparation. e-SIDIF uses expenditure classifications for classification and reporting, has modern Business Intelligence tools, and allows disaggregation in the Chart of Accounts. It records multi-currency accounting entries, has an automated bank reconciliation feature, and is linked to other systems such as COMPR.AR, CONTRAT.AR, LOYS, and GAT, contributing to greater transparency. Program Budget - Last Three Fiscal Years 18. The Government's NIHP is fully integrated into the MSN’s budget. Based on the budget classification by Program, Activities and Expenditure Categories the NIHP can be clearly identified within the overall Government program. 19. The PforR prioritized 10 programs and 14 activities within the NIHP, based on their scope and volume of resources. These prioritized programs will not be co-financed by other multilateral development institutions, but by national funds. The total resources for the prioritized activities of the NIHP amounts US$1,713 million for the period 2023-2025, representing 56 percent of total Government program. 20. Overall, the MSN follows an orderly process for the preparation and approval of the Program budget, as per the process described above. The budget is prepared with due regard to Government policy, but realism is severely affected by the high inflation rates, as evidenced by the latest three fiscal years (2020, 2021, and 2022) that present high deviations between the aggregate expenditure outturn and the approved budget. 21. The NIHP budget for the latest three fiscal years was prepared based on the expected inflation rates issued by the National Institute of Statistics and Censuses (INDEC), which were 34, 29, and 33 percent, respectively. However, these inflation rates proved to be unrealistic, as the actual inflation rates were significantly higher at 36, 51, and 95 percent. In practice, to manage the impact of these higher and more realistic inflation rates, the Government performs budget revisions throughout the year as inflation rates rise, adjusting allocations accordingly. 22. The table below includes the budget outturn from the revised budget, which mostly shows deviations under 10 percent, with only two cases showing deviations under 15 percent, and one case with a deviation greater than 15 percent. Table A4.1. Budget vis-à-vis Actual Expenditures, 2020-22 PforR prioritized nine programs (excluding Central Activities) 2020 2021 2022 Actual Expenditure (Million AR$) 35,212 185,451 121,692 Original Budget (Million AR$) 17,310 78,314 147,630 Revised Budget (Million AR$) 41,316 195,052 150,586 Budget Outturn from Original Budget 203% 237% 82% Budget Outturn from Revised Budget 85% 95% 81% Source: Integrated Financial Information SystemeSidif, Ministry of Economy, retrieved on May 1, 2023. 23. Despite the need for budget modifications, the Programs are implemented in a predictable manner, as shown by the budget outrun when considered the revised budget. This is supported by the fact that the Program's arrears are not considered significantly high due to improved cash management processes and increased transparency in financial reporting. Page 119 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Procurement profile of the Program 24. Procurement under the Program involves goods and non-consulting services. The project is expected to support lines for pharmaceutical products (medicines, vaccines, diagnostic reagents, medical supplies), logistics operation services for the storage and distribution of pharmaceutical products, fixed assets (medical equipment, computer equipment, ambulances, medical vehicles), non-personal services (impressions of guides, protocols), system services such as an e-learning platform, administration and management of stock of medical products and supplies, and minor associated services for vaccine warehouses. Procurement planning 25. The annual procurement plan is prepared by the Procurement and Contracting Directorate of SGA based on the technical requests of different technical areas of the Ministry. It is then authorized by SGA and approved by the Minister of Health through an administrative act. Once approved, procurement processes under the national legislation for goods and services are published and executed using the national e-procurement system (COMPR.AR). The procurement planning is linked to the availability of budget as no procurement activity can be initiated in the system without selecting the available budget line. Fiduciary supervision will include monitoring on the timeliness of budget availability to identify if this system’s feature becomes a bottleneck for implementation. Budget Execution Treasury management and funds flow 26. Adequate arrangements are in place to transfer Program funding to the MSN, ensuring that the funds are aligned with the implementation plans and disbursed in an organized and predictable manner. 27. Overall, it is expected that the central government procedures will be used for treasury management of Program funds, using the Treasury Single Account, held at the Central Bank to manage all government financial resources. The government cash management procedures are well-developed and Treasury balances are calculated and consolidated daily. The operation of the Treasury Single Account is tracked through e-SIDIF, as the main instrument used for recording, monitoring, and controlling the budget and tracking the financial execution of government expenditures and revenues. A budget execution record is kept by each entity and consolidated in e-SIDIF, which does not allow payments to be processed unless a budgetary allocation is available. This control prevents the occurrence of budget inconsistencies, such as the allocation of funds without considering the availability of funds. 28. To meet funding requirements, the National General Treasury (TGN) prepares an annual financial program. This program is based on the calculation of resources and the expenditure budget approved by the General Budget Law for the fiscal year; then a quarterly and monthly program is prepared for the various subperiods of the fiscal year. As a result, the fiscal, primary, and financial balances are calculated, followed by the financing gap (or cash surplus) per period and per currency. The cash program is monitored daily using a Business Intelligence management tool, which automatically generates a daily report that is delivered by email early in the morning, reporting on the implementation and balance of the Program, and daily debt. The payment period for invoices generated in the procurement and contracting process is established under National Decree 1030/2016 specifying that “the invoice payment period will be 30 calendar days, unless otherwise indicated in the terms and conditions. Nevertheless, payments will be expected based on the monthly cash program and the expenditure priorities contained in the current regulation.” 29. The MSN will manage the expenditures to be made under the Program funds in terms of salaries, Page 120 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) goods, services, and fixed assets. Transfers will be made at the subnational level mainly for services with specific procedures in terms of transfer of funds and accountability. 30. The legal framework and operational aspects for processing and control of public payroll expenses is robust. There are precise rules detailing the selection and hiring requirements/rules for processing changes in payroll and related payments. The operational aspects of the central Government payroll are decentralized to public entities through their human resources departments or the equivalent, which are responsible for managing individual personnel files and for preparing payroll runs, using their own applications. Payroll runs must be submitted monthly to the Administrative and Financial Services (SAF) departments to process the payments to public service personnel. 31. Payroll payments are processed electronically through global payment orders issued by the MSN Administration and Financial Services department in the e-SIDIF. Payments are processed against accounts in the Treasury Single Account system. The payment orders are received by the National Accounting Office (CGN), for verification of signatures and data consistency, and are then sent to the National Treasury, which transfers resources to each entity’s account in the National Bank. 32. All central government-owned assets, including lands, inventories and livestock are managed by the State Property Administration Agency. This agency is a decentralized body within the remit of the Chief of Cabinet’s Office and regulated under the National Decree 2670/2015. The accounting information on balances and transactions of non-financial assets is recorded in e-SIDIF at the level of general ledger accounts but it is not reconciled regularly with State Property Administration Agency records. 33. Transfers on social programs (including health) at the subnational level are governed by a comprehensive regulatory framework in place and effective under the MSN. National Decree 892/95 and complimentary regulations define a mechanism on the financial transfers on social transfers between the Federal Government and the subnational level for the efficient use of the resources assigned for the fulfillment of the goals of the intended activities. These programs are executed within the framework of bilateral agreements to be subscribed with the Provinces and/or Municipalities with requirements in terms of flow of funds, internal and external controls, financial reporting and accountability of the transferred budgetary funds, among others. The MSN approved this accountability mechanism through the MSN Resolution 920/2021. 34. Disbursement of Bank loan proceeds will be made at the request of the Borrower upon achievement of results (DLRs) associated to DLIs. Some DLIs (see DLI matrix) are scalable, thus allowing for disbursements to be proportional to the progress towards achieving the targeted DLI value. Other DLIs are not scalable, as the indicators relate to actions that are either achieved or not. 35. Verification protocols - Verification of the DLIs, including the Prior-Results will be undertaken by the National Internal Audit Agency (SIGEN), which is the Federal Government's Internal Audit Agency, under the jurisdiction of the executive branch. SIGEN, has the capacity to provide independent verification for the DLIs and to ensure credible verification of its achievement. The Independent Verification Agent selected is acceptable to the Bank, and has the necessary independence, experience and capacity of ensuring a credible verification. 36. The MSN will prepare technical reports to document the status of the achievement of DLIs. The technical reports will be verified by the Independent Verification Agent, appointed by the MSN, as per Terms of Reference agreed with the Bank. On validation of the achievement of the DLIs by the Independent Verification Agent, the MSN will communicate the achievement of DLIs targets and corresponding values to the MSN. 37. Results achievement notification. The MSN will notify the Bank of DLI targets achievement, supported by the relevant evidence and documentation. Following the Bank's review of the complete documentation, Page 121 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) including any additional information considered necessary to confirm the achievement of the DLI results, the Bank will confirm the achievement of the DLI(s) targets and the level of Program financing proceeds available for disbursement against each DLI. 38. Disbursement requests (Withdrawal Applications) will be submitted to the Bank by the MSN using the Bank's e-disbursement (Client Connection) system. A copy of the Bank's official communication, confirming the DLI achievement, should be attached to the disbursement requests. 39. Under the PforR Operation, funds will be disbursed from the Bank to the Borrower for the timely availability of the funds to implement the Program. The disbursements will be made to a segregated MSN account in the Treasury Single Account held with the Central Bank and denominated in US dollars, based on the achieved DLIs targets. An amount of US$50 million, 16.7 percent of the PforR operation is expected to be disbursed on account of the DLIs met by the Borrower between the date of the Program Concept Review and the date of the Legal Agreement (Prior Results). 40. PforR Advances will be available under this operation. The Bank will advance US$40 million (13.3 percent) of the Program funds for one or more DLIs to be achieved. According with the Bank’s procedures the sum of Prior Results and the Advance will not exceed 30 percent of the financed Program. 41. To request an advance, the MSN will attach a “request for advance” letter to the Withdrawal Applications, according to the sample included in the Financial Information and Disbursement Letter (DFIL). Proceeds of the advance will be disbursed to an MSN account held in the Banco de la Nación Argentina denominated in US dollars. When DLIs are achieved, the amount of the advance is recovered from the amount due to be disbursed under such DLIs. The advanced amount recovered by the Bank is then available for additional advances (“revolving advance”) for a maximum of US$40 million (authorized allocation). When an advance has been provided and the DLIs are achieved and verified, the advance is always recovered first. If the amount allocated to a DLI that has been achieved and verified is larger than the advance, then the Bank will disburse the amount in excess of the advance as a Reimbursement. 42. With the advance provided by the Bank, MSN plans to boost and expand activities included in the PforR program scope. The MSN will continue to develop mechanisms and tools to institutionalize Government programs. 43. Loan should not exceed the total amount of Program expenditures. The General Conditions state that if, after the Closing Date, the Borrower fails to provide the Bank with evidence satisfactory to the Bank that the withdrawn loan balance does not exceed the total amount of Program Expenditures (payments made on or after the Signing Date but before the Closing Date), the Borrower shall promptly refund the Bank any excess amount of the withdrawn balance upon notice from the Bank. 44. The operational arrangement for the transfer of resources will be described in detail in the POM. Accounting and financial reporting 45. The “Cuenta de Inversión”, essentially the Federal Government’s annual financial statements, are prepared by the CGN following national financial reporting and accounting standards (cash transitioning to accrual) in accordance with the requirements of Law 24,156 of 1992, and complementary regulations. The annual financial statements cover the Central Government, including social insurance funds. The AGN, which reports to the National Congress, audits the financial statements. The last accounts audited by AGN were those of 2017. The Law 24,156 of 1992, also empowers the CGN to set public sector accounting standards. The International Public Sector Accounting Standards have not been adopted, but CGN has begun to develop public Page 122 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) sector accounting standards that are harmonized with accrual basis International Public Sector Accounting Standards – although there is no clear timeframe for doing so. There are written policies and procedures covering all routine accounting and related administrative activities and only authorized entities and persons, may change or establish new accounting principles, policies, or procedures. 46. In addition to recording the Program’s transactions in e-SIDIF, the Federal Government system specially designed for the execution of multilateral finance operations, the System of Financial Administration and Control for Agencies Executing Foreign Loans (UEPEX) will be utilized to maintain the overall Program’s accounts (US$1,713 million), using information extracted from e-SIDIF. UEPEX provides a good ex-ante internal control framework, and it is considered adequate for accounting purposes. The cash basis of accounting will be used to record the Program’s transactions. UEPEX can produce financial reports and accounting and financial staff are adequately trained to use and maintain the system. Reconciliations are also performed between the information reported in e-SIDIF and UEPEX. 47. The e-SIDIF/UEPEX systems will be used, to generate the annual financial statements using the cash basis of accounting, both in the currency of Argentina (Argentine Peso-ARS) and in United States Dollars (US$). The SGA within the MSN will prepare the semmi-annual Interim Financial Reports (IFRs) and will submit them no later than 45 days after the end of each reporting period. For the purpose of presenting the information in the Program's currency, for the conversion of balances in local currency (Argentine Peso-ARS) to United States Dollars (US$), the exchange rate at the date of each of the Bank´s disbursements will be used to perform the Program Expenditure Reconciliation in local currency. The SGA withing the MSN will prepare the annual financial statements that will be audited. The Ministry of Economy will be responsible for liaising/coordinating (and, if required, contracting) the audit of the PforR Operation’s annual financial statements and will be submitted to the Bank within six months after the end of each fiscal year. Procurement processes and procedures 48. Procurement processes implemented by MSN follow the national framework that includes: (i) national legislation regulated by the Central Regulatory Unit (ONC) and (ii) special regimes based on technical cooperation agreements approved by the National Congress, particularly with the Pan American Health Organization (PAHO) and UNDP. The national legislation is integrated by the National Constitution, Delegated Decree 1023/01 that establishes the procurement framework for the central administration, Decree 1030/16 that regulates such framework, the procedures manual produced by ONC, a standard bidding document for goods and services, the e- procurement system (COMPR.AR) manual and other legislation that regulates specific aspects such as the national regime to buy local inputs, among other. Even though the regulation includes several different pieces, it is publicly available in ONC’s website and a national legislation website. 49. Open competitive methods are the default approach under the national legislation for goods and non- consulting services. The procurement methods include public open bidding, private bidding and simple awarding (direct contracting). Direct contracting under the national law includes both: addressing a single firm for specific justifications identified in the regulation or conducting a request for quotations. 50. Special regime with UNDP is regulated by National Law 23,396, the UNDP Procedures for Programs and Projects in Argentina, the agreement signed between the MSN and UNDP in June 2020 and its standard bidding documents. MSN applies this special regime on specific activities with extended delivery dates in a context of inflation, as it provides the possibility of including a price adjustment formula, that the national procurement framework does not allow. The specific agreement between MSN and UNDP indicates that MSN is exclusively responsible for planning and executing activities within the program, submitting financial statements, supervising all responsible parties, managing funds and auditing. These arrangements are expected to be followed within this Page 123 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Program and this regime is expected to be limited to specific selected contracts for pharmaceuticals deemed to require price adjustment. Procurement under this special regime applies the international open competitive method as the preferred approach. The framework indicates the specific thresholds under which the following methods can be applied: international or national competitive bidding, limited international bidding (to prequalified bidders), requests for quotations, requests for proposals, local procurement and direct contracting based on specific justifications. 51. Special regime with PAHO follows Decree 1007/2000 and Agreement between the Argentine Republic and PAHO ratified by Law 26,256, and PAHO Revolving Fund Management Procedure Manual. This arrangement is operationalized through MSN using a PAHO revolving fund for the procurement of some recurrent vaccines and pharmaceuticals that implies that the bidding and negotiations are carried out by PAHO with prequalified suppliers that are then offered to MSN for its consideration. 52. The national administration counts on a standard bidding document for goods that defines general procedures for bidding and evaluation that each procuring agency is responsible for defining specifically. The national legislation does not provide standard qualification requirements and therefore, each procuring agency can determine these parameters. Based on the examples reviewed for this assessment, those requirements as implemented by the Directorate General of Administration are relevant to the type of procedure. Nonetheless, to avoid restrictions on participation within the Program, it would be advisable to recommend that contracts under the Program do not include any restrictions other than the necessary aspects to fulfill the requirements. Regarding the participation of foreign firms, the national standard bidding document allows them to submit a bid and therefore this should be considered under thePprogram. Regarding the application of special regime with UNDP, the procurement processes are governed by standard bidding documents that enable open competition. 53. For the implementation of procurement processes of goods and services under national legislation, the administration has a mandatory use of an e-procurement system (COMPR.AR) where all the activities are widely published, bids are received, evaluated and awarded and every procurement record is registered in the electronic management system (GDE). The use of COMPR.AR guarantees that all procurement processes, as well as the outcomes of the awarding, are widely published and preserves the integrity of the process as all bids are encrypted until bid opening. The use of the system is open and free of charge. Participating bidders must be pre- registered in the Government supplier database which implies entering a few data in the system. Processes are also published in the boletín oficial and in the case of international bidding, it also includes publishing in United Nations Business Development. GDE is also applied under special procurement regimes (UNDP and PAHO). The use of GDE enables traceability allowing a proper monitoring of procurement processes. COMPR.AR system will also provide the necessary data to support project supervision. 54. There is a market analysis when initiating a request and the reasonableness of costs is assessed for every procurement activity for standard goods and services. Before initiating a procurement activity, MSN carries out a market analysis to determine estimated unit costs. During the evaluation of bids, MSN analyses the proposed awarding price in comparison to market price. If prices are considered abnormally low or high, the national legislation allows requesting the necessary information to further analyze them and decide. Contract administration 55. There are several controls in place to ensure that goods and services delivered comply with bid specifications. The regulations indicate that the contracting authority has the responsibility to control, inspect and manage contracts, which includes the possibility of imposing penalties in case of non-compliance. In this line, the regulation includes the role of a Receipt Committee, which serves to monitor the execution of the contracts, verifying if the goods received and/or the contracted services fully comply with what was contractually agreed. Page 124 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) The technical specifications from the bidding documents provide a means of comparison with what is delivered. MSN constitutes a Receipt Committee that verifies the quality and quantity of the goods before issuing a final receipt act. Until this document is issued, the final payment is not released. 56. Contractual disputes follow the regular administrative process where the awarded firm can submit a complaint to be resolved by the Contracting entity. If such dispute is not resolved through this mechanism, the following step is to submit it to the judicial court. Additionally, although Law 23,619 approved the New York Convention on the recognition and enforcement of foreign arbitral awards, there are no special provisions in public procurement laws to demand compliance with a decision based on a dispute resolution mechanism. Complaint Mechanism 57. The national procurement system has a complaint mechanism that can be used to challenge contract award. The system of complaints is governed by the provisions of Delegated Decree 1023/01 and Decree 1030/16 and Provision 62/16 of the ONC. There is a period of three (3) business days for the submission of complaints after the communication of the opinion of the pre-adjudication commission. Complaints are submitted through the e- procurement system (COMPR.AR) and become publicly available on the website. Complaints from bidding companies or individuals follow the usual administrative procedure for any governmental act and are addressed by the entity that performs the contracting in a first stage. Following the administrative procedure, the firm can then resubmit the complaint to the following superior stage within MSN. Filing a complaint requires to submit a guarantee that is returned if the complaint is not dismissed. Submitting a complaint may postpone a procurement process if there is strong evidence of wrongdoing. As a next step, bidders can submit their complaint to the judicial courts. Procurement performance 58. The Bank team reviewed data of contracts awarded under this Government program scope January 2018 to December 2022 (423 procurement lines) to analyze procurement performance based on the following indicators: Page 125 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Table A4.2. Procurement Performance Indicators Average length of With the national legislation, the average length of processes since they are published until contract procurement is signed takes 5.4 months for public bidding, 4.4 months for limited bidding and 3.6 months for processes direct contracting (which also includes requests for quotations). Similar figures are reflected in application of UNDP regime: public bidding takes approximately 5.5 months, requests for quotations 3.4 months and direct contracting 4 months. Most of the time spent to complete a procurement process goes on (i) preparing bidding documents and technical specifications (70 days for public bidding) and (ii) evaluating bids (93 days for public bidding). Time for For public bidding, there is an average of 17 days to prepare bids, for limited bidding, this average preparation of bids is reduced to 13 days, and for direct contracting (and requests for quotations) this period takes around 8 days. For processes under UNDP regime, minimum time for preparation of bids is 30 calendar days. Distribution of Under the national legislation, 78 percent of the number of activities and 88 percent of the total awards by amount were awarded through competitive methods (open public bidding, limited bidding and procurement requests for quotations). The rest of the activities were awarded through direct contracting mainly method for unique capabilities (representing this justification 8.8 percent of total awarded amount). Under the UNDP special regime, based on the list of 32 activities reviewed, 83 percent of the number of activities is procured through competitive methods and 18 percent of total executed amount. This figure is explained by one outlier procured as direct contracting that took most of the contracted amount (81 percent) during the analyzed period. Bidders’ Under the national legislation, there is an average of 4.8 bidders when competitive methods are participation being analyzed. Similar figure indicates public international bidding under UNDP regime with four bidders on average. Quantity of There are some categories that were procured in more than two procurement processes per year processes to buy (e.g., antibiotics, antivirals, immunosuppressants). the same item 59. Based on the procurement performance analysis, competitive methods are applied by default in the major number of activities following an average length consistent with the applicable legal framework. However, it was also identified that the largest activity in terms of amount under the UNDP regime was procured by direct contracting. In average, there is an acceptable level of participation when competitive methods are being applied. Efficiency has opportunities to be improved by: (1) reducing the time for preparation of bidding documents and evaluation period, and (2) promoting a higher level of consolidation of activities for the same goods to reduce administrative costs and gain larger economies of scale. These indicators will serve as a baseline to monitor procurement efficiency and the application of competitive methods during project implementation. Internal controls 60. The internal control environment to be used for the Program is anchored in Argentina’s legal and institutional framework. The internal controls relevant to the Program include arrangements to provide reasonable assurance that: (i) operations are conducted effectively, efficiently, and in accordance with relevant financing agreements; (ii) financial and operational reporting is reliable; (iii) applicable laws and regulations are complied with; and (iv) assets and records are safeguarded. Transactions processing will use the Federal Government’s internal approval processes and systems, that provide for reasonable segregation of duties, supervision, quality control reviews and reconciliation. The processes flows appear to be well understood. Page 126 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 61. There are specific units responsible for carrying out, managing and monitoring each of the different program variations with specific monitoring systems used for each, following detailed norms and regulations . Thus, there is adequate control over and stewardship of Program activities and funds. 62. All the Program’s transactions will be processed within e-SIDIF and UEPEX, that enforces strict segregation of duties, controls the preparation and approval of transactions to ensure that these transactions are properly executed and recorded (i.e., different units or persons authorize the transaction and record the transaction), and guarantees the confidentiality, integrity and availability data. The four stages in the budget execution cycle: authorization (gasto o crédito autorizado), commitment (compromiso), verification (devengado), and payment (pagado) are reflected as separate stages/control points, and thereby ensure adequate segregation of duties. e-SIDIF and UEPEX contains a series of controls, which effectively limit expenditure commitments and payments to cash availability and approved budget appropriations. 63. All accounting and support documents are retained on a permanent basis, using a system that allows for easy retrieval for the authorized user. 64. The Program’s internal control system will be documented in the POM. The POM will comprise descriptions, flow charts, policies, templates and forms, user-friendly tools, tips and techniques to ensure that the approval and authorization controls continue to be adequate and are properly documented and followed with adequate safeguarding of the Program’s assets. The POM should be prepared by the MSN and be approved by the Bank and be maintained/updated throughout the Program’s life. 65. The Access to Public Information Law (Law 27,275) regulates the right of access to public information. The Law, which considers “all government-held information” to be public, was approved by the National Congress in September 2016 and entered into force in September 2017. The Law provides procedures for processing information requests, covering obligations concerning disclosure, and the duty to provide data in an open format. The law also envisages sanctions – not yet determined – for those who deny access to information and determines exceptions that normally comply with international standards of freedom of information, inter alia, national security, defense and international relations; public safety; the prevention, investigation and prosecution of criminal activities; privacy and other legitimate private interests; commercial and other economic interests, be they private or public. A new Agency for Access to Public Information was created, which will operate within the Executive branch, although “with operational autonomy,” according to the law. The Agency was created to ensure compliance with the law. Its functions include advising people who seek public information and assisting them with their request. 66. The Code of Ethics for Public Servants of the National Executive Power was approved by Law 25,188 of October 26, 1999, and contains the set of rules that pertain to the conduct of public servants and includes penalties to be applied for non-compliance with these standards. The code informs the principles and duties of public servants, as well as qualities of the public servants, their obligations toward the well-being of the population, and the prohibitions and punishments derived from the irregular service of their functions that recall the fundamental principles of public administration. 67. Decrees 201/2017 and 202/17 are additional control and transparency and integrity mechanisms in judiciary and procurement processes to avoid officials’ feasible conflicts of interest. These rules incorporate additional transparency and monitoring tools in judiciary and extra judiciary processes and in any procedure in which de government awards a contract. A special and more transparent procedure is created in cases where firms and suppliers state they have a judiciary or extra judiciary conflict with the Federal Government or any relationship with the President, Vice-President, Chief of Cabinet, Ministers or any official involved in procurement processes. In both cases, every file should be advertised to allow to be checked and monitored by any citizen. Page 127 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Internal audit 68. The Project will be subject to internal audit by the Internal Audit Units of all the executing Federal agencies, as well as the SIGEN, which is the Federal Government's Internal Audit Agency, under the jurisdiction of the executive branch. SIGEN is an integral part of the Federal Government’s internal control system providing the following core services: (i) assessing the adequacy and effectiveness of the internal control system (internal audit of the executive branch); (ii) supervising and coordinating the actions of the Internal Audit Units and approving their audit plans; and (iii) compliance auditing of procurement processes and contracts. 69. SIGEN can carry out its audits, after prior notification to the organizational unit being audited; it documents its findings and reports directly and continuously to the President. SIGEN has unlimited right to information within the scope of their audit mandates. It has access to all premises and facilities and is authorized to conduct talks with any member of the organizational unit being audited to clarify questions. 70. SIGEN relies heavily on the use of data and the analysis of information from the sectoral and transversal systems to perform its duties; the financial system (e-SIDIF), e-procurement system (COMPR.AR), GDE, and the open data portal are key sources of information . The Bank is actively engaging with SIGEN to: (i) provide access to the Business Intelligence Tools that the Secretariat of Public Innovation is deploying in the Administration to better analyze existing information in the several digital platforms available to allow SIGEN to effectively produce high-quality reports; and (ii) design and implement an open Government plan, to publicly disseminate SIGEN’s own reports, as the internal audit reports are not easily available for public consultation on SIGEN’s website. 71. The Internal Audit Units of the MSN with oversight from SIGEN prepares and executes annual audit plans aimed at setting up systems to anticipate potential non-compliance, irregularities and identify opportunities for improvement in management processes. The Internal Audit Units executed and completed 22 audit reports on 2021 comprising all the programs with exception of two that were moved for 2022. SIGEN through its Quality Assurance process for the year 2021 concluded that the Internal Audit Units of the MSN is adequately staffed for the achievement of its objectives in a timely manner. Also, it is worth mentioning that for the year 2023 SIGEN included in its annual plan the Program 29 of the MSN: Access to Medicines, Supplies and Medical Technology that is included in the PforR program. To the extent that internal (or external) audit reports become available in the future relating to any of the Programs, the status of the auditors’ findings and recommendations will be followed up, during implementation support missions. 72. SIGEN established a Federal Public Control Network (Red Federal de Control Público) with the subnational governmental control entities. The objective of this network coordinated by SIGEN is to evaluate the performance of social programs (including health) implemented by the Federal Government within each province, municipality and commune. This network integrates and complements the state control and audit structures at all state levels. It also strengthens the control environment for monitoring and evaluation of transfers to provinces under this program. Program Governance and Anticorruption Arrangements 73. The Criminal Code (Law 11,179) establishes responsibilities, accountabilities and penalties for officials and citizens in relation to acts of corruption. Furthermore, Law 27,401 establishes criminal liabilities related to bribery, traffic of influences and illicit enrichment, inter alia, for both domestic and foreign companies, state- owned or not. 74. In Argentina, bribery offences, whether domestic or foreign, are federal crimes. Investigations may be initiated by a complaint made by any person to the police, public prosecutor, or judge. Allegations of corruption Page 128 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) could be filed at the Office of Anticorruption either by e-mail, anonymously or with protection of identity, at the Office of Administrative Investigations (Procuraduría de Investigaciones Administrativas) or at the Government Agency where the offence took place. 75. Public officials who become aware of the commission of a crime while performing their duties, must report it to the authorities. Enforcement authorities are legally required to commence the investigation once becoming aware of a bribery allegation. The investigation is conducted by the investigating judge or can be delegated to a public prosecutor. Once the investigation is completed, the judge may decide whether the matter should move to the oral trial stage, in which case a separate judge or judicial panel conducts the trial until its completion. There is thus institutional capacity to monitor and address governance and corruption issues. 76. The Bank’s Institutional Integrity Vice-Presidency (INT) may also, jointly with the Borrower and/or MSN or on its own initiative, investigate any allegations or other indications of Fraud and Corruption (as defined in the ACG) in connection with the Program or any part of the Program. In all such cases the Borrower and MSN will collaborate with Institutional Integrity Vice-Presidency (INT) to obtain all records and documentation that Institutional Integrity Vice-Presidency (INT) may request from the operation regarding the use of the Program financing. If the Borrower or the Bank determines that any person or entity has engaged in Fraud and Corruption (as defined in the ACG) in connection with the Program, the Borrower will take timely and appropriate action, satisfactory to the World Bank, to remedy or otherwise address the situation and prevent its recurrence. 77. In order to implement the Bank’s Anticorruption guidelines for PforR operations, it has been agreed that any expenditures arisen out of contracts given to individuals or firms debarred by the Bank or under suspension by the Bank are not eligible for Bank financing under the Program. The national legislation already requires public entities to perform a verification of suspension or debarment on World Bank’s website before issuing an award, despite the source of financing. Nonetheless, the POM will include this verification prior to contract award to ensure a timely application and the external auditors’ Terms of Reference will include a requirement to review Program expenditures to confirm that contracts are not awarded to debarred or suspended firms. 78. MSN will immediately inform the Bank (through e-mail and official letter) of any complaint, claim or allegation related to fraud and corruption which MSN either receives or of which MSN becomes aware; in addition, every semester (together with the Program Monitoring Reports) a report will be prepared containing all alleged cases, with an updated status of the respective actions taken. MSN will immediately provide the Bank with all the records, documentation and information that the Bank may request with respect to such issues. In the event that the Bank decides to conduct its own investigation, the Bank may request the Government and/or MSN to exercise its/their legal rights and remedies (under the relevant contract/s) so as to obtain all information, records and documentation that the Bank may request, and provide these to the Bank. This process does not limit the rights of the Bank to also make direct requests for information from individuals or contractors who are recipients of Bank financing. In line with the obligations arising under the ACG, MSN should ensure that individuals or firms who are recipients of Bank financing are aware that the Bank may decide to exercise this option. If the Bank determines that it has not been able to receive the documentation, records, or information requested by the Bank directly and/or through MSN, the Bank may declare the relevant expenditure ineligible for Bank financing under the Program. Furthermore, should the Bank conclude that a sanctionable offense has occurred, it may decide to pursue sanctions against the individual or firm in line with Bank procedures. Auditing 79. For purposes of the Program, the external audit will be conducted by the AGN due to its mandate. The AGN is the current auditor for Federal-level projects being financed by the Bank and has the capacity to deliver a Page 129 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) quality audit on time. In the event that the AGN is not able to conduct the audit, a private auditor acceptable to the Bank will be hired to conduct the audit. 80. The AGN has been assessed with a high level of independence based on international standards and practices, including legal, financial, mandate, coverage, and operational dimensions. The 2021 Supreme Audit Institutions Independence Ranking prepared by the World Bank included AGN in a High Independence category where most independence indicators were met. 81. The AGN will follow agreed Terms of Reference acceptable to the Bank and will conduct the audit in accordance with the International Standards for Supreme Audit Institutions, a framework of standards formulated by the International Organization of Supreme Audit Institutions (INTOSAI) or national auditing standards if, as determined by the Bank, these do not significantly depart from international standards. 82. The audited Program financial statements will also be prepared using the cash basis of accounting, both in the currency of Argentina (Argentine Peso-ARS) and in United States Dollars (US$). 83. The auditors will be required to issue an opinion on the Program’s annual financial statements and produce a management letter in which any internal control weaknesses are identified, with a view to contributing to the strengthening of the control environment. The auditor’s report will be submitted to the Bank no later than six months after the end of the fiscal year. The Bank will review the audit report and will periodically determine whether the audit recommendations are satisfactorily implemented. 84. The Bank also requires that the Borrower disclose the audited Program financial statements in a manner acceptable to the Bank and following the Bank’s formal receipt of these statements from the Borrower, the Bank will also make them available to the public in accordance with the World Bank Policy on Access to Information. 85. There is currently an outstanding financial audit for a World Bank projects97 managed by MSN through its SGA with the support of the DGPFE. External audit is being carried out by the Supreme Audit Institution, AGN. The external auditors' work is closely monitored by the Bank’s team and the Government.98 86. With the purpose of continuing to strengthen the AGN’s capacity and knowledge for the PforR instrument, agreed actions are detailed in the Program Action Plan that include periodic training provided by the Bank to the AGN auditors and coordinators. Procurement and Financial Management Capacity 87. MSN has a team of experienced fiduciary staff (Financial Management and Procurement) and is responsible for the implementation of the Program’s integrated fiduciary aspects. Staff are experienced and knowledgeable on governmental policies and procedures, and although they have prior experience in implementing Bank Investment Project Financing (IPF) Operations, this will be the first PforR Operation. 97 (P173767) AR: COVID-19 Emergency Response Project with closing date on April 30, 2024. 98 According to Bank Procedure on Program-for-Results Financing, if the specific agency that will be responsible fully or partially for the financial management of the Program funds and/or submission of audited financial statements and accompanying audit reports under the proposed Program/loan has an overdue audit under an existing or closed loan from the Bank, clearance will need to be granted justifying proceeding to Negotiations notwithstanding the overdue audit. Page 130 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) D. Program Systems and Capacity Improvements Table A4.3 Fiduciary Risks Risk Mitigation action Timing Type of Responsible Data sources action for the to monitor action progress MSN´s The Bank's fiduciary teams will provide During POM MSN with POM unfamiliarity close implementation support. As an implementation. support Completed with the PforR effectiveness condition the MSN will POM will be an from World Instrument prepare a POM. effectiveness Bank condition. Risk of Detailed disbursement plan with clear During MSN Disburseme inadequate timelines and accountabilities should be implementation nt Plan planning of the established and communicated national regularly, while also providing training resources and capacity-building activities to transfer to the provincial authorities. Provinces Delays in the Disbursement of funds to an MSN During POM MSN Client availability of account held in the Banco de la Nación implementation Connection funds for Argentina denominated in US dollars. Program activities. Delays in the Establish clear deadlines for the During Program MSN Report presentation of completion and submission of audit implementation Action Plan submitted audit reports reports and implement an effective on time may increase coordination between MSN, AGN and the risk of Ministry of Economy to monitor the financial progress and identify any potential inaccuracies or delays irregularities going unaddressed for a prolonged period of time Potential The implementing agency will be During Program MSN Report omission in required to comply with the World implementation Action Plan submitted verifying firms’ Bank’s ACG, the POM will include the and audit’s during eligibility requirement to verify eligibility before Terms of supervision before awarding a contract, MSN will be Reference. mission awarding the requested to provide regular reports indicating contract regarding the list of contracts and the the list of external auditors Terms of Reference awarded will include a requirement to review this contracts as Page 131 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) condition also. Additionally, there will be well as a clear reporting process for any confirmatio allegations of fraud and corruption n on within the Program to ensure that the whether Bank is promptly informed. This will there were enable the Bank to assess the adequacy any of the reporting and investigation complaints mechanisms provided in the Bank's Anti- regarding Corruption clauses and take appropriate Fraud and action to address any issues identified. Corruption within the Program. Implementatio Promote internal procedures to enable During POM MSN fiduciary n delays in the coordination, reduce the time for implementation systems definition of preparation of bidding documents and assessment technical evaluation period, and a higher level of indicators specifications consolidation of activities for the same using and in the goods to reduce administrative costs COMPR.AR evaluation of and gain larger economies of scale. report and bids information on UNDP processes. Potential Bidding documents should not include During POM MSN POM restrictive any restriction of participation other implementation completed requirements that the requirements to fulfill the including on bidding technical need and following the this documents, national standard bidding document, requirement giving the fact allow foreign firms to submit bids. . that national legislation does not count on standards to define them. Application of Whenever possible, promote the During POM MSN POM direct application of competitive methods implementation completed contracting following national legislation and UNDP including method under framework. this UNDP special requirement regime on . largest activity. Page 132 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) E. Implementation Support 88. The proposed fiduciary implementation support includes the following: (i) Reviewing the progress of implementation, with a focus on the achievement of program results and the implementation of the Program Action Plan. (ii) Monitoring the performance of fiduciary systems and audit reports, including the implementation of the Program Action Plan and application of the PforR ACG. (iii) Monitoring the PforR financial statement reporting process and providing assistance to the client as necessary. (iv) Monitoring changes in fiduciary risks of the Program and, where relevant, ensuring compliance with the fiduciary provisions of legal covenants. (v) Reviewing the implementation of the Program with the sector team to assess the timeliness and adequacy of the Program's funds appropriation. (vi) Assisting the borrowers with institutional Financial Management and procurement capacity building. (vii) Continuously assessing and monitoring the performance of the Financial Management and procurement systems under the Program and providing suggestions for improvement. Page 133 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) ANNEX 5. SUMMARY ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT 1. The Bank, in accordance with World Bank Policy on Program for Results (PforR) Financing OPS 5.04-POL 107, carried out an Environment and Social Systems Assessment (ESSA) of the country’s health system as applied to the Program for Universal and Effective Health Coverage and to the Integration of the National Health System (henceforth the “Program”), under a PforR financing mechanism.99 The scope of the ESSA was to evaluate the systems promoting environmental and social sustainability, and assess their ability to: avoid, minimize or mitigate the potentially adverse impacts associated with the Program affecting natural habitats and physical cultural resources; protect patients and caregivers and worker safety; consider issues related to indigenous peoples, ethnic groups, underserved groups100 and migrants; and avoid social conflict. In addition, it identified the actions required to improve and strengthen national systems and mitigate potential environmental and social risks. 2. The specific objectives of the ESSA purport to: (i) identify the potential benefits, risks, and environmental and social impacts applicable to the Program's interventions; (ii) review the policy and legal framework related to managing the environmental and social impacts of the Program's interventions; (iii) assess the institutional capacity for environmental and social management systems within the Program’s system; ( iv) evaluate the performance of the Program’s system with respect to the basic principles of the PforR instrument and identify gaps, if any; and (e) submit recommendations and actions to address gaps and improve performance during program implementation. 3. The PforR will be based on four Results Areas (RAs) aligned with (1) cost or efficiency, (2) quality, and (3) access. Cost or efficiency refers to the financial burden associated with healthcare services (including the cost of medical procedures, medication and insurance) and the need to minimize the resources required to produce these healthcare services. Quality refers to the level of care that patients receive, including the accuracy of diagnoses, the efficacy of treatments, and the overall experience. Access refers to the availability and affordability of healthcare services, including the availability of medical service providers and insurance coverage. 4. The RAs are as follows: (i) RA1: Consolidated and institutionalized health financing mechanisms. The activities falling under RA1 establish mechanisms and processes that lay the foundations for the results to be achieved in other Results Areas. (ii) RA2: Increased equitable and effective coverage. This RA seeks to enhance the fairness of the coverage provided by key health services. (iii) RA3: Improved quality and integration of care in the public sector to health services. This RA seeks to support the Government with the implementation of measures to improve the quality and integration of health services. (iv) RA4: Improved efficiency through the coordination and integration of the health system. This RA seeks to support coordination between health systems at different levels to improve efficiency. 99 Innovative financing instrument for the Bank's client countries linking the disbursement of funds directly to the achievement of the results specified. 100 Based on the suggestion received during the ESSA consultation, the term vulnerable groups, which was considered stigmatizing, was replaced by the term underserved groups, which emphasizes the need for the State to make a greater effort to overcome current access barriers and provide adequate healthcare. Page 134 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) 5. Regarding the environmental component, the World Health Organization (WHO) points out that the waste generated by the activities undertaken by health establishments, such as contaminated needles, sharps, chemical, cytotoxic and radioactive waste, have a higher potential risk of producing injuries and infections than any other type of waste. The incorrect handling of this type of waste can lead to serious consequences for public health and a significant impact on the environment. 6. The main environmental risks and impacts of the Program, as well as the focus of the ESSA, are centered on: (i) healthcare waste management; (ii) the potential generation of electronic waste, prompted by dismantling equipment as a result of the scheduled obsolescence of the electronic devices required to provide effective and efficient quality health services; and (iii) the impacts of natural disasters and those caused by the effects of Climate Change (CC), due as much to their direct impact by interfering with the dynamics of the provision of healthcare services, as to the interruption of telecommunications services or their effects on the health of healthcare workers. 7. From the social point of view, the ESSA evaluates the barriers preventing underserved groups, including indigenous peoples, from accessing or participating in the Program. It also evaluates the structure of the agencies involved, and the mechanisms for consultation, participation and attention to grievances. The ESSA takes into account the risks of creating or exacerbating social conflict, especially in fragile states or situations such as those involving migrants, ethnic groups, and remote or isolated populations. Variations in land ownership regimes, including commonly-owned resources, customary or traditional rights to land, or the use of the resources and the rights of indigenous peoples, are not considered in this Program. 8. This Program is expected to bring about vital social benefits, particularly by improving the quality and efficiency of the health services provided. The Program will include a transversal gender perspective, in particular by: (i) training health personnel in gender and diversity issues; (ii) providing technical assistance to the provinces to ensure that a gender and diversity perspective is taken when providing primary medical care; (iii) developing outreach communication strategies that contribute to gender and diversity perspectives; and (iv) designing and implementing a medical procedures guide to help identify people who have suffered or suffer GBV and ensure the right level of care is provided. 9. The social risk is considered “Moderate”, since even the Project is expected to produce positive impacts on underserved and systematically excluded groups, and not lead to any negative social impact, there are risks associated to possible exclusion of underserved groups, including indigenous peoples, from accessing the Program’s benefits. This risk will be mitigated by strengthening intercultural health, gender and diversity actions, as well as communication, stakeholder participation and the grievance handling on behalf of the MSAL and through the Provincial Ministries of Health (MSP). On the other hand, there is no land acquisition, resettlement, or loss of access to natural resources, and there is no serious risk of exacerbation of social conflicts. 10. The environmental risk has been considered “Moderate” as no constructions will be carried out, nor will any areas associated with cultural heritage be intervened. The Program’s actions and investments are planned within the footprint of current health establishments and will not affect any biodiversity protection areas. However, it is possible that there may be some (minor) increases in healthcare waste management (healthcare waste101) which may be due to improvements in the quality of services, and to the early diagnosis and treatment of diseases such as cancer, during the early stages (until such medical practices become more common in the 101healthcare waste management, a process to help ensure proper hospital hygiene and safety of healthcare workers and communities. Page 135 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) universe of services). In addition, the potential generation of Waste Electrical and Electronic Equipment (electronic waste) as a result of the implementation of the Program contributes to the risk qualification. The operational phase may present certain risks and impacts associated with the management of medical waste and other solid and liquid waste within health facilities (segregation or selective collection by category, packaging and temporary storage), as well as the transport, treatment and final disposal of solid medical waste, with special attention to hazardous waste. If not correctly managed, these activities will pose a threat to the environment, public health, and occupational safety. The institutional setup has the potential to develop the capacity required to deal with potential environmental risks and challenges. Dispersed populations present disadvantages for the final treatment of Healthcare Waste (healthcare waste102) and electronic wastes, which are related to operational difficulties. 11. ESSA confirms that the current system to manage the environmental aspects of the Program is reasonably covered by institutional regulations and capabilities, as the National Ministry of Health (MSN) establishes the governing policies. healthcare waste management is run as an intramural compliance system, under the responsibility of each establishment, and in extramural terms, it is regulated by the environmental authority of each jurisdiction. The legal framework regulates the all-around environmental and health management of waste created by the healthcare sector and other activities. At subnational levels, the Provinces are responsible for managing healthcare waste and electronic waste in their jurisdictions, although there are differences between them in terms of their regulatory and management frameworks. The provisions of the existing environmental legal and regulatory framework are adequate and require their institutional and technical capabilities to be enabled in order to comply with them. So far, a National Law for the comprehensive management of electronic waste has not yet been enacted, and only some provinces have one in place. The use of electronic waste as post-consumer materials within hospital management has not been clearly established. 12. The results of the ESSA confirm that the current systems deployed by the Federal Government to manage the environmental and social aspects of the Program are well rooted in a robust legal framework designed to provide equitable and inclusive access to health services. 13. The ESSA findings identified a generally satisfactory level of implementation of and compliance with current medical waste management regulations, although it is not possible to verify the national integration of healthcare waste management at provincial levels. 14. To maximize the benefits of the Program, ESSA proposes three environmental actions and four social actions as part of the : Action 1) about “Healthcare Waste Management”, to strengthen the respective area of the MSN responsible for collecting and processing the relevant information, compiling evidence to assist with decision-making in producing evidence-based governing policies, and to contribute to scaling good practices throughout the health system, in accordance with the MSN’s quality policy; Action 2) linked to the “Treatment and final disposal of healthcare waste”; Action 3) to strengthen electronic waste management; Action 4) to strengthen the approach to intercultural health and underserved groups; Action 5) to address gender and diversity gaps; action 6) to strengthen instances for citizen participation and claims handling at both national and provincial level; and Action 7) to provide the MSN with a tool for a sustained approach to social conflict situations with the potential to undermine the development of healthcare and develop intercultural health measures. In addition, ESSA recommends strengthening training mechanisms, using the successful experiences developed by the MSN during the implementation of projects using World Bank financing, as well as networks articulating environmental health experts from all jurisdictions, and networks at provincial level articulating key referents from each 102 healthcare waste, which is separated according to category. Page 136 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) establishment. In the same way, it recommends strengthening and scaling up the self-assessment system intrinsic to healthcare waste management in establishments offering inpatient and outpatient care, as well as Occupational Health and Safety. 15. Special attention should be given to monitoring the main health impacts arising from Climate Change given the latest findings about the greater frequency of extreme events of different characteristics affecting different areas of the country. Page 137 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) . ANNEX 6. PROGRAM ACTION PLAN Action Description Source DLI# Responsibility Timing Completion Measurement The National Technical DLI 1.1 MSN Recurrent Yearly Capitation Value revised. Ministry of Health (MSN) shall revise the capitation value to cover the provision of the essential package of health services for the population covered exclusively by the public health sector and thereby enable results under RA2 and RA3 The MSN shall Technical DLI 1 MSN Recurrent Yearly Population Estimations revised. revise the estimations of population covered exclusively by the public health sector; which are used as a basis for the calculation of the Nation- Provinces Integrated Transfers and the Transfers to the high-complexity disease Fund The MSN shall Technical DLI 1.2 MSN Recurrent Yearly High-Complexity Disease capita revise the value revised. capitation value to cover a high- complexity benefit package for the population covered exclusively by the public health sector. This capitation is the basis for the calculation of National Transfers to the National Page 138 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Fund Healthcare waste Environmental MSN/CSA Other (a) Within 4 a) Focal Point (FP) in each Management: and Social months of province (a) strengthening of Systems framework b.1) FP trained (>30%) governance agreement b.2) MSN Annual report on schemes; signing; HCW and vaccine waste (b.1) 3 (b) strengthening management months of institutional c.1) Network creation after capacities; and framework c.2) Training (c) knowledge agreement c.3) Analysis of year-on-year management and b.2 trends based on AR (point B). annually; (c.1) 7 See ESSA for details months after effectivenes s and c.2 & c.3 Annually Healthcare waste Environmental MSN/CSA Other (a) (a) 6-monthly access to (HCW) Treatment and Social Semiannuall information about HCW & Final Disposition Systems y, after management capacity; Create knowledge framework (b) database updated in about installed agreement Research Electronic Data capacities for HCW signing, (b) Capture (RedCAP)/REFES on treatment and final Annually. (c) HCW management; and disposal first report (c) Annual report on HCW 7 months generation vs. treatment after capacity program FA, then an See ESSA for details annual update WEEE in health Environmental MSN/CSA Other (a) (a) Report on WEEE sources; system and Social Annually; (b) Good practices & recovery a) Identify potential Systems (b) the third mechanisms Manual; sources of WEEE year; (c) (c) annual report on WEEE annually; (d) b) Dev. of good training; the third practices & post- (d) WEEE recovery program year; and consumption (Proposal); (e) recovery of EEE Semiannuall (e) 6-monthly access to c)Training on EEE y, after information on WEEE use & recovery Framework management. mechanisms agreement See ESSA for details d) Design a WEEE signing recovery program e) Create a data base of WEEE recyclers Develop and Environmental MSN/CSI Other (a) Within (a) Focal Point in each province implement and Social the first (b) Guidelines for Provincial Page 139 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) guidelines for Systems year of Plans Provincial effectivenes (c) Reports containing Intercultural Health s; (b) assessment of provincial Programs and for annually; (c) implementation; underserved annually systematization of UG health groups information and stakeholder (UG),including engagement activities strengthening of See ESSA for details governance schemes and institutional capacities. Develop and Environmental CSI/MSN Other (a) Within (a) Assessment of participation implement a and Social the first instances & GM consulted & strategy for Systems year of disclosed stakeholder effectivenes (b) Strategy for stakeholder engagement and s; (b) to the engagement and GM grievance second developed, consulted & mechanism (GM) in year; (c) Bi- disclosed the health sector annually (c) Implementation reports after the second year See ESSA for details Develop and Environmental MSN/CSI Other (a) As part (a) Provincial Commitment implement a and Social of the signed procedure for Systems Framework (b) procedure developed addressing agreement; (c) Implementation reports situations of social (b) Within 4 conflict that months of See ESSA for details compromise the framework implementation of agreement healthcare actions signing; (c) Bi-annually Fraud and Fiduciary MSN/Secretariat of Other Any time Possible allegations of Fraud Corruption. Systems Adm Management during and Corruption, timely Promptly inform (SGA) implementa reported. the Bank of any tion credible and material allegations of fraud and/or corruption regarding the Program as part of the overall Program reporting requirements Transferring funds Fiduciary MSN/SGA Recurrent Continuous Detailed disbursement plan, to provinces: Systems timely reported. Detailed disbursement plan with clear timelines and accountabilities Page 140 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) should be established and communicated regularly. Establish clear Fiduciary MSN Recurrent Continuous Audit reports completed and deadlines for the Systems timely submitted to the Bank. completion and submission of audit reports through effective coordination between MSN, Ministry of Economy, and the Gov. Supreme Auditing Institution (AGN) to monitor the progress and identify any potential delays. . Page 141 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) ANNEX 7. IMPLEMENTATION SUPPORT PLAN 1. The Implementation Support Plan is in line with the Bank’s Program for Results (PforR) operational guidelines. The Borrower is responsible for the implementation of all Program activities in support of achieving the agreed Disbursement-Linked Indicators (DLIs) as well as actions to correct inefficiencies and bottlenecks identified in the social, environment and fiduciary assessments. The Bank will tailor its implementation support in technical, fiduciary, environmental and social aspects to ensure the following: (i) Provide technical advice for the implementation of the Program Action Plan, the achievement of DLIs and elimination of other social, fiduciary or governance-related bottlenecks relevant to the Program; (ii) Review the Program’s implementation progress via program progress reports and other relevant information; (iii) Advise on and review documentation prior to official submission for the fulfillment of Disbursement- Linked Resulrs (DLRs) as may be appropriate (iv) Monitor performance under the Program Results Areas (RAs) and monitoring compliance with legal agreements, keep records of risks and propose remedy actions to improve Program performance, if and as needed; (v) Provide support in resolving any operational issues pertaining to the Program, including reviews of grievance redress mechanisms; (vi) Monitor the performance of fiduciary systems, potential changes in fiduciary risks of the Program, and the Program’s performance in terms of timely availability of financing for the planned activities; (vii) Monitor the Program financial statement preparation process and assist the Borrower as necessary; (viii) Review the Program annual financial and procurement audit reports and management letters, discuss with the Borrower and monitor the implementation of the auditor’s recommendations; (ix) Monitor and help the Borrower as needed with institutional fiduciary capacity building. In particular: • review implementation progress and achievement of Program results, including effectiveness and quality of procurement planning, timeliness and competitiveness of the procurement processes; • provide support for implementation issues and institutional capacity building, as relevant; • monitor the performance of the fiduciary systems and audits, as well as compliance with fiduciary provisions of the legal covenants and the Program Action Plan. 2. The following major categories of support are envisioned: (i) Implementation support and capacity building relating to the RAs and DLIs that require technical assistance and support from Wourld Bank staff and consultants. Examples include: (i) strengthening results-based financing mechanisms and their institutionalization; (ii) calculating and verifying result- based financial transfers to provinces; (iii) reviewing the drug list for centralized procurement (based on criteria from evidence-based medicine, health technology assessment, and budget impact analysis) as well as the procurement methodology; (iv) strengthening and formalizing a high complexity healthcare network; and (v) building capacity on health system strengthening focused on the integration of the health system. (ii) Supervision of operation, technical and fiduciary review: supervision will be conducted on a regular basis. Page 142 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Table A7.1. Main focus of implementation support Time Focus Skills needed Resource estimate* First 12 1. Program Operations 1. Operations and Three visits of the core months Manual (POM) implementation support team to review the 2. Result and Monitoring 2. Monitoring and POM and train on PforR Reports Evaluation implementation. 3. Financial Reports 3. Health financing 4. Documentation for 4. Health information TA support as needed submission of DLI’s systems by specialty areas evidence according 5. Quality of care verification protocols 6. Fiduciary 5. TA for the initial 7. Environmental (climate milestones of DLIs change) and social (Gender) 6. Fiduciary 7. Environmental and social 12-36 1. Program operation and Regular supervision months process visits 2. Monitoring and 1. Operations and evaluation TA support as needed implementation support 3. Health information by specialty areas 2. Monitoring and system and big data Evaluation 4. Documentation for 3. Health financing submission of DLI’s 4. Health information evidence according systems verification protocols 5. Quality of care 5. Technical Assitance for 6. Fiduciary the annual DLIs milestones 7. Environmental (climate and for implementing the change) and social (Gender) activities under each RA 6. Fiduciary 7. Environmental and social Mid-term Assessment of Program Operation, Monitoring and Conduct visit for mid- review achievement at mid-term; Evaluation, Program term assessment Potential restructuring evaluation, Fiduciary, environmental and social systems expertise 3. The World Bank core task team will include the task team leaders (senior operations officer and senior economist), technical specialists (health specialists and economists), and procurement, financial management, environmental and social systems specialists. Team members are based in the country or region to provide prompt support and follow up on implementation of the Program. Expertise from the Health, Nutrition, and Population Global Practice, as well as from other practices will be drawn upon as needed. Page 143 of 144 The World Bank Program for Effective Universal Health Coverage and National Health System Integration (P179595) Table A7.2. Task team skills mix requirements for implementation support (per year) Skills needed Number of staff Number of trips Comments weeks Senior Operations Officer (task team Country based 10 3 leader) Senior Economist (task team leader) 10 3 Region based Program Leader 5 3 Country based Health Specialist 5 3 Country based Senior Economist 5 3 Country based Technical Consultants (strategic International and in-country purchasing, quality of care, benefit As required As required package design, and health information systems) Procurement Specialist 5 Country based Financial Management Specialist 5 2 Country based Environment Specialist 3 2 Country based Social Specialist 3 2 Country based Page 144 of 144