Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No. 11790-AR

STAFF APPRAISAL REPORT

ARGENTINA

MATERRAL AND CHILD HEALTH AMD NUTRITION PROJECT

JULY 14, 1993

MICROGRAPHICS

Report No: 11790 ARType: SAR

Human Resources Operations DivisionCountry Department IVLatin America and the Caribbean Region Office

lTis document has a restricted distnbution and may be used by redpients only in the performance oftheir offical dutes. Its contents may not otherise be disclosed without World Bank authoization

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CURRENCY UNrr - PESO (AS)

EXCHANGE RATE(as of March 15, 1993)

US$1.00 = A$1.00

F[SCAL YEARJanuary 1 - December 31

WEtIGIIS AND MEASURES

The metric system has been used tbroughout the report.

FOR OICAL USE ONLY

GWSSARV OF ACRONYMS

APIS Snmia and Finac niea SubqCDC Chid Dvelomen CetrCNMN Natioa Maternal ad Ch Pmgia (Compmmis

Nacional A avr do la Madre y el Nd)R40 Food nd AgticuFSC Fde Sg Co_GDP Gws Domestc Pnduct ( do" Infeino BEuo)GNP Guss National Product (Producto Nacidonal Bruto)RS Federal Healt Secrsariat

IDB Inter-Ameran Delpmett BankIND1C Natonal Instit of Stastcs and Census ([sdtuto

Nail de Es1ska y Cww)MCH Matrna and Child EalthMCEN Maera and Child Healh and Nutiton ServicesNW Municipal Eecuting UnitMSAS Miistryof Heakh and Socil Actio (M ro de

Salud y Acci6n Social)NGO Non-Govemental O nPAHO/WHO Pan A n eakh Health

BagsInsurance FundPAN Naonal Food Piogmm (ln Nacional de

PCU pruject Coriain UiPEU pwincial Executing UnitPMH PQwinca Ministres of HealEMTS P t Ma -nagmenfomao SubystemOO z for Economic Coopeqtion ad

DeveopenOS Social Inme Funds (Obras Socales)SAMCS hged s Pubic Health Ara ServicesSDMIS Service Delvery Montrn and Infrmation

SubsystemSSAL Social Sector Ma e Thic Ascstne lamTPS Ibhnical Pmjects SecetratUNDP Unitd Nato Development PwgmmmeUNCEF United Nations Ckild's Fbnd

i document has a rstd distibuton and may be used by cipient only in the peromaneof thei offil dutis Its contents may not otherwi be dsclosed witout Wor D authorizton.

ARGENTINAM1ATERNAL AND CECLDPWALTH AND UTRITION PROJECT

TABLE OF CONTENTS

LOAN AND P!ROJECT SUUAMARY ................................ i

1.BACKGROUN ............ 4......... .......... A. Ilonoi Sefti g ............................. 1 B. SocblConidon . ..................... *... ......... }C. Womeni Developmen ................................. 2

2. SECTORAL CONTEXT ................................... 3A. EqlXeat and Nutdion Stas ............................ 3B. 7h ef aeSyt ......................... I...... 0. SC. HedthCan andFianciago iSw .............................. 7D. EHealthCanRsucs andUtization ................................... 8fI a m an"Ld Child Heah andNutM*k Serices and Pw s ........................... 11P. PmshxilSerices andPedoranc ................................... 12

3. SUbBlURY OF$EICTOR LESUES AND GOVER3eET STRATEGY ................................. 13A. issus ........................................................................ 13

B. 8oenW utg .................................................................. 14

C. Avaibbeand PbndResourcs forMat nd ChildHealh .................................... 16

4. E XENAL ASSISTANCE FOR TBEESECTOR ........... ...o ......................... 16A. 8ar Rol an sdW Satg ............................................. 16B. 7URoleo Odier Donor .................... ....................... .... isC. Lesn of E.....pe...e..ce...................................... 18

S. TEEP ROECO..............C....T.. 0. 20A. Pqect Orgi ........................... .. ..** *...............20

B. PfgojetObjcdvs,R * s6Sw and Area ........................................ 21C.M NP"a Fas of thePn-je .............................................. 23D. DeMilW PlqeDescdpdo ................. 0... *.................. ...... 23

6. VS IMUTED COSTS AND FINANCING PLAN ......................................... 34A.Coss .................................................... *34D. Fhldng Phn .................................... * .*..*..36C. Reounn C ss adk nbdy ......................................... 38

7. pRojECT BPpLEMENTAIION ............... . ............................ 38A.it Oqnaknnyed Coordinton ......................................... 38B.PKeo ............................................ C. ad Accountsds ................ .. ,46D.AxegAig ....

. Stus of PzgjectPouwa ..... ............ ...... . 47F. Monhoigangd S%rvisin ........................... 48G. id-Te,nNReview .................... . * ... . .. .. 49

B. Risks. * *om ntal. .pa ............... ....... ......... . .o 499.A Ih4aton Women ................ .................... 549

n. Pr: EJEct AND P...... .......................... 42

A. BondsX ..................... ........... 49D. RAie ....................P.... SO

9.nex C: OrganREIzIoNaS.Cbarts . . .. ..... .. .............. ...... 5SO

Anex : PSrojeco C land Pai tniias......... ....... ...... . S2Anma B: PngeaCosts .............................. o 53

Annex C: opzb ChuU ............................ S8AnnexD: Sdpn-eo Cycl a lic4dd okn CdWda ..... ....... o....... 60A ex B P and Disb Cycle . .......... ....... . 65

Armex F: MonitoringIdit .. .................... 66Anmx G: SupevisionPlarn ......................... . ........... 78AnmexH: Docunmesin Phoet's WodnFieandGb Q= Fie ................ 80

MAP. IBRD # 24782

lis repot is based on th fndinp of pawraisal and api missions tat visied Argntn inOctoberNovember 1992, and March 1993, rqpecbv. Msion membes ibludd Mi/Mm. JOsBAdsu (Mission aTnd Sr. Projet Officer, LA4HRA ; Patrio V. M(bc Heat Seiaand A na Mission Coordinator, LA4WI; Fncic Mardon_e (Nutri Seist, LAT ; JuanGiacoli (Public Healt Specst, Consan); Edmond Andrews nformai SYsms SpecialitConua); Vita Didonet (Child Devdop t Specialst, Consant); d Anit Au (OpeaioAssista Consulta). Ms. Jewnif r Feande (Staff Milant, LA4WR) provided a oms in thpoducton of this report. Task _naor. Jose Ank= (A4H; DMsi C .hif: an S*weie(LA4R; Director Pg-eung Loh (LA4); Powr R1fr : Jane (bow (ASMI; SaHm Hab(SA2P; ad Alan Brg (P DR). Mr. Wllim Mayvle (LA4DR) edotd th report

ARGENTINA

MATERNAL AND CIHD REALTH AND NPlITON ROJECT

LOAN ND !ROJECM SUMMARY

Borrower Aitine Repubic

B _: Ptovince andMu b

Amount: US$100 million, eqivalet

T,nV: Repayment in 15 yeas, iluding a 5 year gmcr pedod, withintrest at the ks sandatd variable re.

Project Objecties: Th prposed project would assist the Goverment in mwovingthe heat and natrXit stu of poor mothes and chklden andpCO cn can and devlpmn of £ p

wtin pag d s p Ai,Cordoba, Ente RicO, dendoM Sana Fe, and nTcumn). Thproect would also upport Goement effort to decetmlzsocia service eat and financing fom the provinces tothe . lbp. ewouldbetaretdtopromoteffcie nd sevmice qualiy improvements in exsigmaternal, child health, nurdon and eary childhooddevelpmen progrmms. Th prjec would fnac, on the basisof pmdefimd cdooda, hwegment and incremental operatingexpe a with the defivyof maenl and chldheath and ntiton, and early cildhood deveopme savie.

proect Deepeio Thepr has tree4pr comppl:

(a) Matna, Chld Heath, and Nutrllon: T componentwould reifore the caciy of mtrnal and child health andnutrtion progmns to provide app ate and imely care tolo come moes and chin, both on an ambulatory badsand in matriy wards and neonatl units of local hopitals. Tots end, the project would support the delivery of a page ofbasic health and nutrion services that integmte healtrom oo disease prevention, eady detection, and tratmet

inevntos

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promotim, disea prevention, early detecton, and treatment

(b) EarlY Childhoaod Development Comnponent: The aim ofthis component is to sport mental and socil development ofchildren between the ages of 2 and S years. To this end, theprject would spport the progressive transformation Ofpreschool feefig pmgms and idens into childdevelopment centr where services would be offered, incldmnutrt, motivadonal actvities, and preschool education.

(c) gttIoaoStromponent would eancethe long-term capcity of provinces and muni forplaing, mnaging, and implementig mothr and child-relatedaces. Under this component the project woud finanetning activities, information system, soomm,tehnical assistance for nizing school feeng programs,and stdies. The project would also finance the preation of asecond opeato

Epcted Be: The princpal benefit of the proposed pioject would be incasedaccess to health and eady child development servies formotes and children di in low-income pe-urban areas.Project interventions would improve ift and dil sudrvaland matmal heah, reduce the prvalence and severity of themost common diseases, and promote the care of young chidrn,ehasizing their physical, intellectual, and social developmentThe proect would also niie a process of manageial andoperationa imp itvements in proviial and muncpa sociaprograms for the deivery of MCHN and early childhooddevelopment services. The involvement of pwvinces andmunicpalties hr teir subpjects would improve teiovea planning and ilemeion capac.

Ri ad Sa -qbguad: in geneal, provincial and munipal hea adm ingna is weak, and this lits the poteta for proving

and expanding services. However, the ptrect has a simplodesig, and woud build on prvailng arrange . Politicacomitent is strong both at the national and the local level,and is likely to be suined, not only because MCHN is anadonal issue transcending poltical parties. The prject istargeted on a hand of munici in six prvines whichcontn laWe nmb of poor, bave fiscal and ad intive

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owetvs aod p Bm bm be ofndd and

di kaddtn_nd Only Zvortyeof. at Ur_II 1 and upeieltlto wotdd

pmmd mdoWy in each provine, dIminshing fth tisk of_otenb affetng the proect as a whole.

dt stnzta and norms would be used, and

nndgb bod nph d budea coD_m usmtechical ft would be provided to from

thefdetu and povincial levels. UNDP and local agenciswould pwveds wpport, whle oheroa_gcies would be oved with tining, montodg, andcommunity Feibe Sguidine wouid permitdevloin sytem mow In e wit local conditons.

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Esdtnted Costa: Local Fog Tota % of d e Cost-~US$ mi, ----

Components

ProvI. and MmialSu bpiojnb 116.8 6.3 123.1 82Nalos Ntition SurW5 5.6 0.0 5.6 4Pipjoct Iact Evaluaon 1.9 0.0 1.9 1S"tu, Avdie d iS anr Ta AmisTonA_ 1.5 0.0 1.5 1Social o Cami 4.0 0.0 4.0 3Insttdoma Dsvlmat 4.0 0.0 4.0 3PCU 10.3 0.1 10.4 7

TOTAL BASE COST' 144.2 6.3 150.6 100Phydel Co 0.8 0.0 0.8P&Gco Cm5-_a 8.6 0.0 8.6

TOTAL lOJECT COST 153.6 6.4 160.0

NANCING PLAN

source Pftject Cost Dudes Toal lent of CostLocal Form Total & TPXiS Cost Project Toal

Bakn 96.0 4.0 100.0 0.0 100.0 65.0 62.SPWrad l Gowvmmt 31.8 2.0 33.8 6.2 40.0 22.0 25.0Pion 19.6 0.4 20.0 0.0 20.0 13.0 12.5

TOTAL 147.4 6.4 153.8 - 6.2 160.0 100.0 100.0

EAdmated BRDM FY4 FT" FT% F FY ms

Annual 11.0 21.6 22.0 21.7 14.4 9.3Comutiv 11.0 32.6 54.6 76.3 90.7 100.0

Ecumic Rae of Returu Not applhbl

Pqty CdAqo:y PrSya of tWgct intervandons

ARGENTINAMATERNAL AND CHLD HEALTH AND NITRMON PROJECT

BASIC DATA

Total Ana (Mil'o km2.) 2.8sTal Plopuin M 32.3" -uati Densiy per Sq. Km. 11.0iotal FEt7ty Rate 2.8Crude Birth Rate 21.6Crude Death Rate 7.9Rate of Natual Inwrease 1.4Lf Eectc at Birth (Years)

men 67women 74

infant Mort Rate 25.7Matemal Mortali Rate 7.9Urb~an Populaton as PercentOf Total Popuation 87

Lieay Rate (Age 7 and Above)Males(%) 95.5Femes(%) 92.0

Priaqy School EmollmentMales (%) 97.0Females (%) 95.0

Age Structre0-14 (%) 28.515-64 61.5Above 65 10.0

Pouaon per Physia 425Populon per Nurs 1,800Curent Conutacepve Prvaence Rate (%) 65Per Capita Goss Natoval Product (US$) 2,370

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DEITONS

Age:.pcc Moraiy Deah res broken down for each age groupRates popultion.

Aveage Len of Stay Number of hoil patient-dayslnumber of padtadmissioDs.

Avre Occuny Number of hospisl patient-dayslnumber of bedsRalte mulpled by 365.

Child Death Rats The nmber of deaths among chdren oe to four yea ofage per 1,000 cidre in that age goup in a wive year.

Chronic Di e Those inesses chaed by a long latency perod,prolonged clinical course, and debiitatin m anis .

eTe percentap of mared women in reProductivePvalnce ages who are reguy using a method of c c n

Crxde Bith Rte Number of live births per year per 1,000 people.

Crude Death Raft Number of deats per year per 1,000 peopk.

Dendency Rato Poplfion 14 yean or under and 65 years or older as aperoentag of the populao aged 15 to 64 years.

Incidence Rate The number of persons cnt a diseae as a proporionof the population at risk, per unit of time usually expresedper 1,000 pero.

infan Mortaiy Rae Annual deOa of inant less than 1 year old per 1,000 livebirths during the same year.

Lifo Expec Ihe number of yeas a newbom dcdld wouldat Bihth live if subject to the age-spcif mortaity rues prevaiing

at time of birth

Maral Monty Number of materl deaths per 10,000 lve birth aes 'm agiven year attribable to pegnancy, childbirth, or post-pMim.

*Mrbit Disease and illnes in a poulation.

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Mortality Death in a popuaton.

Prmvae Rats Ihw number of persons having a patdcar dises at agiven point in time per populatio. Usuay expsed per1,000 persons.

Rate of Naumi Dfece betwee crdeb and cn deathIncrease rates; usuay epessed as a pp .

Rate of Popaon, Rate of natua Ica ah usted for (net)Growth migation, and expressed as a pentaep of the total

po;tion in a given year.

Total Fett Rate l be averpge mmber of chaiden a woman will have if sheespdam a gen sat of age-specific ferity utet (ie.,

those then prevalig among women of toe ages)her lifetime. Serv as an esmate of the

muaer of children per iimily.

ARGENTINA

MAT:RNAL AND CMLJD HEALTH AND NUTRMON PROJECT

STA APPRAISL REPORT

1. BACLGROUN

A. conomi Setng

1.1 Argna wfuered a prologed period of economic decli duing the1970s and 1980g. Savigs and investment rates pbumeted in repon to the-astae eonmic dcimae. Capital fligt contbuted to worsening

and poverty. Mm cuncy was often devaed, and the rtoof public debt to GDP ro to near 100 pecent. Chni public sctordeicits Ate nfaio and could not be controled by four majorStaimUonprgLs.

1.2 The present a which took power in mid-1989, quklyproceeded to address the m M oo withssucces. Maj rform Inlded drm"aaly reduing public deict,pegging the peso to the US dollr, late scde pi of publcenerrie, and imprving reenue-sharing with te provinces. As a resulof the and other _meu, the combied public setor deficit lQ.Sp Prentof GDP in 1989 was eliminatd andrspacd In 1992 by a .6percnt surplu. In 1991 and 1992, GDP grew on averg between 8 and 9percet per annum.

B. Soda Cond_it

1.3 Economic conditions for the poor have impwved over the la tbryea. Ih elmination of theinflatlon ta hbas beneited the poor more thnother income grmups, open unmpo,n has drpped and rea wagos Inmost sctors are higher than in the late 1980s. N, the dtatio ofth poor in Argnina stil requi more dirct aggresse acton by teGovermt

1.4 The economic ciss of the last two decades had an unven Impactamong two diffen grou of poor. Th estmated 2.2 mi aditorual poor who live maiy in the nortbhe a northweste pwvinces

mise, Cho, Pomoa, Juy, Sa La Riqa San Juan, Santiago delho, Caamarca, and Tucumn) were paRy dshedd from the Ml

efecs of economic ersion by supporve family s,uctur, acoess to bascstaplews sugb agrlcnx u, and pau-time menL

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However, the 7.5 million urban poor presen a moo dicult and uretcha_en to the Govenmt Ths group Includes nal mig s and theur unployed, who live In the povert belts snu la andmedium-sized ubn aeas, such as Buenos Aires, Rosdo, Tucuman,Cordoba, and Mendoza. Poverty among this gwup is me markd taomog the ftrditonal mmrl poor in tems of relaive incomes, housin,satay condions, and food itae. Wage eans aug this group haveedxprnced major setb duog the 1980s:- first, toug fallinincomes (ra Inome declined by more than 35 peroe), ad second,though incasing eployment (frm 4 prcent to mo¢e than 12 percent)Nd u (estmaed at 20 percet of o labor fce in GteterBuenos Aih in 1989) caused by economic condioantd nir-to-umiaon that mseled the ranik of job-seekrs.

1.5 Reduced public investme in housing, wat supply, adworseed the plight of the poor in pei-urban aes. The 1980 Ceulassied almost 30 percent of housg uits as unsanitay or uns as. In

1989, it was beleved that shanties and temprar dwelling accounted formost 50 percent of housing in the law udn perpheres, a 50 petrase sine 1980. Data fm the 1980s indicate that 31 percent of the

popaon in lare udan areas did not have access to safe waer, and 45percn did not have aces to sewage services.

C. Wm In Dweopet

1.6 No reliable ses on the role of women have befn caded out InArentn and chnging economic and soca coita bave hidered theidetifcation of a clear pa of women's employmnt rats and relaeincomes, power dationsin the f y, and outside Ini nc-activtis Over e Us two decades, however,aibl Infom showsthat female nolmet in udaun primary and seconday edcton hasimproved almost to the level of males. Over the same perd, wom'sparticipin in paid loymet ieased frm about 1S to 35 percet,adho theI employment of women b w in lowski, even mea, jobs and on inform actvt gies low bcomes.As discussed below, and smilar to may other develoing cuntie,matenal moralt and morbidity remains a mjr ue affectg women'shealth (pai 2.7)

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2. SECTYORAL CONTEXT

A. Population, Heath and Nutrito Status

2.1 Popuation. Argentina's total population, 32.3 mio in 1990, ispaqected to rise to 36.5 mMion by 2000. Popuati density, at 11inhabitas per square kilometer, is the third lowest in Latin America afterBolivia (5) and Paraguay (7). Population per square kiome of agiuludland is a mere 16, the lowest for Latn America. e popuon Is gwingvery dowly: the 1989 crue birth rate (CBR) and the cude death rate(CDR) were, resp.-dvely, 21.6 and 7.9 per 1,000 population, bading to antural popuaon incra of 1.4 pent per yea (the tbird lowet in LatnAmerica behind Urugay, 0.5 percent, and Cuba, 0.7 pcet). If the

esen deog ic dc , the country would rach an annulpopulaon growth rate of 1 percent by 2010. Mhe to frtilty e (TPC )was 3.1 in 1965, 2.8 in 1989, and is projected to dece to 2.3 by 2000.Th 1980 census showed that low and decining frility is associated withurbanition: rual families had an aveage of 2.9 chidren as compared toan average of 1.9 chldren for udran fmilies. nesi p t £ofwomen in the labor force and female educaion, and use of contraceptives by70 percwe of the uban populion contrbuteo oeduced feilty.

2.2 In 1989, life epctancy stood at 67 yeas for men and 74 years forwomen, with wide disparite among provinces. Life ectn was 7 yearsabove the avewa for middle inm dveMping couia. The poplatios aging as a reault of the sustained declie in the ferdily raft, and anincrase in life expectancy. In 1989, a high 10 percent of the populto was65 years and older, which was comparable to the rtio pvallg in

strial soees; the proportion over 6S is expected to Inra to 14percent by 2010. The pwportin of the popuaton 15 years and youngrcontrce from 31 percet to 28 percent during the 1980s. While the

-pendency ratio is expected to dere slightly (frm about 66 in the mid-1980s to 60 in 2000) becase of a declining birth rate, the dqgroupwm inclutde a growing propotio of eldedy people who wM rei costlymedical care and social secuity benefits paid for by the shdinking pof the employed.

2.3 The poplatin is overwhminfgy urb By 1989, as a result oflr scale migration to cites in sach ofem 87 percen of thepopation was estmatd to reside in ura cen (up frm 76 percent in1965 and 83 percent in 1984). More than 10 millio people or 30 percet ofthe populaton live in the Greater Buenos Aires a.a

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2.4 Health Stau. Argena shows two differ_nt epdemiologicalprofl ofken coexstig in the same geograpbic areas: one, C ndg tothe profile of indstri count, with hIgh incidce of chmnic anddegenerative diseases, and the other, reftg conditions similar to thoseprailn in developing counre, with high incidence of ifctou andpasitic dseas. Due to rapid urbantion and induastraization, as well assignificant changes in lifestyles over the last tbhe decades, the has been arapid ince in the percentage of deat due to cardiovas r dLseases,cancer, and accides, wbich together account for about 70 percent of aldeaths. Th res are attrbutable to other chronc conditions such as diabetesand crhosis, as well as infcous and parasitic diseases, nutitonadeiienies, peumonia and itfluenza, and meningitis.

2.5 Nutrion Status. rlly, Argentina has been a leadingagil procer and epoer, paarly of beef, wheat and soybeans.As a resut it has been beter off than most other Lain Amedcan countriesin tns of aveg per capita avaiablit of caloies and proteins. In the1980s, avenge caloric avaiabiity was 3,386 per day, higher than the FAO-recmmended minimum daily cons on of 2,250 caloi. The per caitdaily ailabilit of proteins stood at 112 gam, well above tie minumrequirement of 54 grams.

2.6 The situation deterioed in the 1980s. Ih federal Miistry ofHealth and Social Acdon (Mnistedo de Salad y AccI4 Socal, MAS)estimated t by the mld-1980s, 30 peen of chldren under 5 years of agewere m shed.Ahough this esdmate may be somewhat high, as anaverage it reflects the nutria problm fcig rurl areas of the ntheprovinces and pei-udan ara. In the absence of any recent survey of localconditions, the nutitonal st of poor chld and mothers can only beinferred from a few isola studies. A household study in Buenos Airesconducted in the mid-1980s found that among a sample of 485 childr aged2 yeas and less, 16 percent were sha as measured by wei-for-age. Height-for-age measient sowed that 24 pct of the childrehad signs of chronic mtin. In the early 1990s, a small sample srveyof pregnant women in a poor area of the Buenos Are Province indicatedtht in the 1st and 2nd tdmesers of pregancy about 20 percent of womenwere underweight; and at the 3rd trimester about 30 percent according toweight/height crteria.

2.7 The Pfght of Poor Mothers and Cbildren Mothers and childz.have suffered the effects of the economic crisis more acutely than oth-members of poor households. Frt, there is a close corrlton betweenpoverty and size of household: the most sgnficant variables associated with

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povty are the dependecy ratio and the umber of childen per household.Housholds with unsatisfied baic needs contin on avage more than twieas many childre as other houseolds. Second, unde medsproportionatel affects mothr, infan and children as a result of thecommon practce of allocating most of the availabe food in the household tothe and male adolescts. Tii inadequate access and lowqualiqt of basic health services specificaly affect mothers and children. Thehigh rates of preventable infant, chld, and maternal mortality are goodindicats of the high prevalenc of morbidity affecting fthos populationgroups.

2.8 Argentina's Infat mortaity rate (DMR) of 25.7 per 1,000 live birthsin 1989 was much higher than in neighboing Chle (16) or Costa Rica (17),counries of simila socioeconomic profile, and thre times higher than inindustr sociees. Moreover, there are major variats in the DM1R acrossregions: IMR is between 1.1 and 1.3 times higher in the lare, poor, pefi-rban areas than the naional aveme (see Technical Anmex A in the Project's

Working File). Three-fourts of the 11,000 neonatal deaths (the majority ofwhich were due to matemal uetii and poor quality obstetic caue)and 60 percent of the 6,300 post-neonatal deaths (most of wwich were due toimmuaopreventable and acute resiatory diseases), which were cnc damong the poor, could have been prevented twough beter mtton andopportune health care in s. Simultnousy, the death rate forchildre 1-4 years (5 per 1,000) and the mabe mortaliy rate (7.9 per10,000) are too high for a country with Argentn's socioeconomic

. Child mortali patterns rflect the impact of the worseningcrisis. While child moryt rtes slowly declined frm 1980

sugh 1985, they stalized or worsened in the following three yearsvituy erywher in the counry. These treds hide worse condionsamong the poor. For chldten aged 1-4 years, the most prevalt causes ofdeath other thn accdents and violence ae infectous and parsitc diseases,

luan and pneumonia, and nutrional ddiciencies, aU of which arelarely preventable. Pernatal and posa cop ns ae the maincauses of matemal moly and morbidity; it is esmated that two thirds ofmatel deaths (relatd to induced abortion, hemorrhage, and toXei) couldhave been prvented by oppotune, good qualiy health care.

B. The Heslth Cue System

2.9 The health sector in Argentina is compleL It deveoped throughsuccessive and often contradictory govenment policies and uncoordiedchnges of healt care providers and financial agencis. There is amutiplicity of health care provies: the federal Government, 24 provl

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govements, hundreds of municipes, oc scuty hospials, the armedforces, prvate hospitals, and idep physici. Complex financialchemes lhave also dev.loped. Third-party payers incde 336 social

insuranc fimds (obras sociale, OSs), more than a thousan muualities,most of them small, commercial insurance companies, and pivatefoundatins. As a result, the sector is an aggregat of many sub-sysmwher providers and fnanciers intct to eat often overapping healthprograms and coverage schemes.

2.10 The Public Sedor. In 1991, about 25 percet of financing and 35percent of coverage were provided by public services. The federl Ministryof Health and Social Action (MSAS) is the main athrt in te country forhealth and social programs. MSAS has been tzaditonally a weak ministry.Partly to address this the govemment rcently restuctued it into six mainsetriats: health, old age, project/technical coopeton,oordiation/ami ton, hsinsil action, and generml (see Annex C,

Chart 1). Under the Bank-assisted SSMTAL piject, MSAS oaioand management and budgetary improvemes are being intrduced. TheMSAS is entrusted by law with policy making, nornaive and rltoryauthoriy. The Health Secretriat (HS) is responsible for coodinaing thehealth sctor. The HS's authority exeds over matenal and child health andnutrition, communicable diseases, sana, occonal medicine, thequality of healh care, and food and dnrg rg on.

2.11 In the federl stuture of Goverment, the Prvincial Ministies ofHealth have full opeaional . Accdingly, each of the 24pronces 1has its own health care system. The operational caacity of theprovinces varies grely (see Technical Anex B in the Project's WoingFile). While stronger provinces such as Buenos Aires, Santa Fe, andMendoza have more efficient minitries and competent staff, some of thesmaller provinces require significant suppot from the MSAS. Provinces areresponsible for opeting cuative flties, plemeing preventive andpublic health programs, and enforcing reguato. Provinci facitiesconsttute the backbone of the public health sysoem. In 1990, their systemcomprised 897 hospits with more than 67,000 beds wich accouted formore tban 33 percent of all admissions in the country. Ding this period1,738 private clinics (with 47,000 beds) acunted for 44 percent of hospitaladmission, and 2,615 health cenrs and disensaies (which received 21million outatiet visits) represned 28 percet of all ambulatory care in tecountry. Some of the r munipal (Bu Aires, Cordoba, Rosario)opeae szeable health senvce networks, comparble to those of a province.The scope, quality and size of these delivery stems vay acording to the

7 -

eaonoic and polIc sregth of the provinces and the extet to whichpeople ane coered by health isurance.

2.12 Belt nsurce. In 1991, the OSs provided 60 percent of totabealt ce financing and 55 percent of coverage. This sbsector is ana_gregIte of many heath insunce schemes rather than an integmted system.As early as 1910, labor unions began to offer medical care plans to theirmembuEs. Bach lurge buiess bad its own union, and most unionsestbished ir own OS. Membership in an OS becme compulsory in1970, and coveage was extended to the employee's family. Besdescontractg with the public or private sector for services, OS also woperatetheir own facilities (apm ly 30 OSs operate a total of 260 oupadtclics, and 114 hospitals with more than 8,000 beds, accounting for about15 percent of total ougiet visits and 6 percent of total hospitaladmissions). In addition to the OSs, some 1,000 non-profit muhtaitis(mutuas) offer het care plans fimded by individ contributions.

2.13 Pvate Sector. In 1991, the private sector was estimated to pwvide8 percent of total heat financing and 10 prcent of covreage (to those whoa affiiates of commercial health insurance plans and/or who can pay out-of-pockt for sevic rendered). This subsector consists of fincaline and providers of health care, though some insttutins performboth functo. Finacial includ commeacil companies and

inancal*- groups. They offer a vaiety of comprehensive health cam plans ona prepaid bas. They also supplement other forms of coverage to pay fordeductil, co-payme, or aditonal benefs. Most private insurers aresmall, hower, and have not yet reached a level of performance comparbleto that of lr heal insuance companies in other countis. Prvatephysicin attend patns who belong to OSs or pepaid hfalto rganzations. it is estimated that the vast majority of physicians are in part-time pvae practice. Physician are organized in influential provincial and

na l asociatons.

C. Health Care ps! and Thaaudng of Services

2.14 Argent's health expenditm share, about 7.1 perct of GDP in thelat 1980s, is as high as in many lower-income OECD coutes (7-8pcent). Tota heath care spending in the early 1990s is about US$7.5bilion; per capita exp iu is appt ximately US$234 with wide variatioamong ocioecnic s. Fedeal and provincial W and othergovenIm revue alocated to health care account for 2.1 percent of GDPao 30 perceat of total heat expendues. Social insance tuxes amount to2.6 percent of GDP or 37 percent of expendiues. Finally, household

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payments, either diect (overwhebmingly for drug pases) or thughprivate health insurance, account for another 2.4 percent of GDP or 33percet of healt exqpendKiture.

2.15 The bu of prvate cae fincing, outside of drug pubhases isprovided by OS. Each OS is mainly finced by payroll axes. A tax of 9percent (3 pOis deducted from th employee's salary packet, and 6 poisadded to the employer's wage bill) is levied at the. source, and paid to theemployee's OS. Consequently, bigh slry sectors canffod adequate heathpla, wbile low salary sectors can offer only limited benefits. Some OSsare laWe t with mre thian one milon afflas, while oths coverody a few thusand members. Of the eisting 336 OSs, 291 are federallycoodinated and legally able to operate in more than oe province, while anadditonl 45 emoll the public employees of provincs, muni, andthe federa Judciay, Congress, and Armed Forces (prvincial genentsbave powers to regulae oly povincial and municipal employee OSs). The5 larger OSs account for nearly half of the total membership in the OSsystem; the laWer 15 account for over 90 peen The rapid growth of theprivate sector was financed by a rapidly expanding OS system. Privatehospitals expanded and bought more equipment, especialy advancedtehnology, as they entered into contacts with the OSs, which provided asable market and a guarateed source of income. A recent PridentialDecree gnt the insured the freedom to choose their OS regar(lessofplace of employment is bound to lead to major consolidati of health

m agencies.

2.16 About 95 percent of public health care fiancing is provided byprovincial ven . MSAS's role is lmited to funding a few highprority pgrams, such as food sue tal and immPwvinial govemM finance health expenditures by (i) collecting taxes onassets and economic tansactions; and (ii) through automatic FederalGovenment tansfrs. Tansfes are channeled twough rvenue sharng oftaxes collected by the Federl Govenment and discretionary gant.Provincial revenue sources are tas on al estae, value added es, andicenses. Provinces, in turn, share their revenues with municipal

D. Health Care Resurce and Utilztion

2.17 Healt care has detrioraed over tTe last two decades. Funing forhealth services has also decrsed. In the public sector, the progressivelylar demand for heal services runs cumnter to dmiished volume andqualy in sector facilities. The health sector's share of dinishing public

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nding from 5.5 pecet in 1978 to about 2 percn during the secondbalf of th 1980s. By 1990, the publc she of total sector financing isestimaed to have decreased further by 20 percen. Social Securt financinghs aLso decreased as a result of bigher unloyment and lower payroll taxcoletons.

2.18 Public services are generally ovetburdened. As a resultof thecontactio of the formal sector of the economy, a lare number of theprvuy insured have bad to seek care in public facies. Prom 1987 to1991, the share of the populaon served by the public sector Is esmated tohave increased from 30 percent to 35 percent, and per capita exp ies n1991 for this gmup amounted to ondy US$108 equivalent.

2.19 Provincidal and municipal public services are pooly eqpped tohandle the volume of demand. The lack of piortis, cleway defined and

d e g sdards, incentves, and affect most

proincial servies. The public health network, both ouatient andinatietciitie, pwvides vAiyg degree of access and quality: while servces are

better i the richest provinces (Buenos Airs, Cordoba, Medoz andNeuquen), they are indequate in the poor provinces of h north and

notwst.

2.20 Imbalanced an poody tained and ilized heath peonnel are majorcase of idency. First, physician ovesafg is gealized. In 1987,Argentina had 78,000 pracdiing pbysicians or one physician per 425 people,twice the level d for cout with similar sooec andhealth conditions. A majority of physicians hold sevral jobs whileunemployment and undeplomt a n on the rise. Staff salaries consumeon averg more four-fifths of provincial operaing resourcs, leavingother (and essential) opeqt inpu bereft of financg. Low saries andpoor incentives and morale, which in tn limit cacity and lower sevicequality, are the direct consequence of physician ovsaffig. During the laSdecade, the quality of taining of medcal s8tents has sufrd fom largernumbers of enans to medical schwols and more limied fndig.

2.21 Second, nwsing is neglected. In 1987, the phYsiannure atio was4.4/1 or eacly the opposite of cost- ent health personnl use. Nurigtraing is not practically oriented: the lmited on-thewjob expedence isconcentrae to the hospital setting. Similafly health techidans are nottraed with adequate equipment and lack expos to wil nm operations.

2.22 Hospital managementf from low pririty and prige. Mostspital manges ate physicians who do not have either the vocation or

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tiing reqired for their mgement jobs and who additionaly e poodypaid (in 1991, local hotal managers' monthly salries avead US$400).

2.23 Effective hospital capacity is limited by opetg weak s In1987, provincial hoits (wbich account for roughly one third ofadmisio) and municipl hosptls (accounting for an addtoal 10 perenof caacity in the larger mcipalities) had a nominl capai of one acutehospital bed per 250 taret popWulation (similr to contons in Sweden).However, in 1987, about one fourth of acute cae beds was notbecause beds were either dilapidated or lad th required suppt services,such as maineance, dgs, and otber operating inputs. In spite of a 12-dayaveuge length of stay (which is twice as high as would bexpected for acounuty of Argentia's healh profile), the balace of q l bedsshowed a low 60 percenav geccncy rate, as compard to 8S'90percent in more efficient systems, due to poor man nt and limitd

ang -.

2.24 Outatin hospital capty is also beig ieficety use asevdenced by slow prcessing of paients and long waiing lists. Lack ofambulatory resoces y increase hoI and costs. Telk of a basic healh can model, low priority m budget allocations, andpoor incenives diminish the role of ambulatoty care.

2.25 Ph ls. The overpesription of drugs rles anohersource of waste. In 1989, Argentineans spent an inotdinate US$56 per capt(mosly out-of-pocket) or about 30 percent of health care financing on drugs,as compared to 12 percent in the United States and other industrhl societies.A law is beiug discussed at present to gant patent pwoe topI products. Ths measure may likely inae the cost of bandname dugs. Under recent legiation, pries have been deregulated andimorts lberlzed, and genec drugs ane being promoted in some provinesin efforts to lower drug expendi. Further effos are plnned to edwe

unwanted compin of drg by emphasizing tighter control ofphycian pcins and over the counter drug purchases. ,

2.26 High Teho. Daring the 1980s, unteguated colog use,together with greater competton for paients among ptivate clinics, led tolaW purchases of advanced e ipment. For example, in 1988 fthproption of CAT scanners in the Buenos Aires metolan ama was Onper 5,000 populaon, fr exceeding the recomme noms in Industialsociedes. Mhe deteioratng fnanc:ial codition of pdvate clinics (due toreduced soc insuvance financing) bas acted as a brake on high tecologyPurases.

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2.27 The bmpact .f Poor Health Services on Mothers and Children.Poor mothers and infts suffer the effects of Iiited sevice delvey in twoways. First, at the ambulaty kve, by not having accss to heathpromotion and disase prevendon intrven. To illustte, in the 1980s,the percentge of Infant fully immunizd before 1 year of age was low:agnst diphtha, whooping coug and tes, 62 percent; tuberculosis, 61perent, and measles, 60 pcet. Low ates of Immunization lead to thespread of commdicable and contrud to iat motality. Inaditin to nial imn campaigns, mote permanent and bettercoordinated delivery systems are needed to reach and maintin highimmunization lvels. Lack of knowledge about rehydration therapiesprecude saving e lives of infants and chilcrenm with severe dirrhea.Secondly, poor snitay and supply condaiom in hospital mateity wardslead to unnecessary deh among mothes with pregnancy and deliverycomplications, and among underwei babies.

E. Matrnal and Child Health and Nutrition Services and Programs

2.28 Health Progmns Oriented to Poor Mothers and Children. Duringthe 1980s, primary health care programs were ostensibly given the highestprioty at the fed, provinia and municipal levels. However, there islittle e spport for pAMny healh we. Health education on topicssuch as controlof smoling and alobol ,diet, useOf p _ and env i hazard is virtually tnoestent.Immunizat,human o (cluding birth spacing, abortion andtee pregnancy), pr-and post-nat care, control of diaioea and acuterepiratory i; control of merging diseases, which prtilarly affectpoor mothers and clildremn, have been reively neglected.

2.29 At the national level, prmary health financing is wasted due to lackof well artculted operatnl progms. At the provincial and municipallvels, health posts, health ces and the outpatient departments of publichospils, which should lead in developing prmary healh care, have nospecif p or budgary provision for this ptupose. Urgentdemands prevail, whiclh fct a lack of leadershlp and incentives amongadministrator and staff to develop health prmotion and disease prevention,outreach sevices to grops at 4k, and public healh campaigs.

2.30 The results of the 1984 National Inst of Statscs and Census(Insiut Nacional de Esadidi y Censo, INDEC) study of poverty gaverise to the National Food Prgram (Plan Naciona d, PAN),first as an emergency measure, and later as a penent instrument foraddrssing the nutiion needs of the poor. The PAN, and its successor, the

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Bono Solidario progam, evenully channld about US$200 mMl'nammaly to local authoies for purchasing and distibuting famy-epacaes of basic food lem . However, program weaknse havenegated most of the potntial benefts, as follows: (a) poor Wget andpoitizaon led to canelng sizable amounts of food to middl Incogrps and te poltialy wel connected; (b) poor m d ilarge scale loss, pilferage, and theft; (c) lack of iteg-ation pdwithpimary careservi£es transfomed the programs into income trasfer mechanisms, insteadof iuwmets to redress Dalnutition; and (d) the lack of benchma survepysand monioring and evaluation fostered poor ac and have hinderdoverall ex-post assesment of outcome.

2.31 Food lemeon prcams bave been dc d andincrpredinto large provincia and municpa welfare programs withiout

the benefit of policy reimproved orgization and magemeand ination with health sees. It is imperative to gan corol ofthese funds, define their healt/n objives and htnsfer theirmanagement to healt cta and other agencies c".ged with this

. Preschool Services and Proranc

2.32 There is a wide gap in sicesforr ole. Childre up to 2year of age have access to heath care sevices for their health and nutritionneeds. School children aged 6 and above ar provided with suppley

fe through school luch prgrams. Those in between, preschoolesaged 2 to 5 years, have no formal sot sstem.

2.33 In 1990, it was esdmated that pr-school-age children with unsatsedbasic needs (relaed to housing, bygie, access to safe water, and healthcare) numbered about 1.5 million. Of thes, about one-third were receivingnutition supplementation and haphard healt care tough pwvindal andmunicipal }iergartens, mothes clubs, and other public and privatechannels. Even this lmited assa was nt well planed or supervised.The widely diffeng oanization ngemets and jisictresponsble for this age group in ovics and m ania, togeher withsmall private sector p t der fts to rtonaize and expsevc. Additionally, virtually no preschoolers from poor famies receivepsycho-social simuaion, iis maks entry in schools more diffict andincrases the rates of repettion and dropouts.

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3. SUMMARY OF SECTOR ISSUES AND GOVERNMNSTRATEGY

A. bsues

3.1 Health Care and Nutrition. Te main obstacles to sectordwelopment include: (a) the lack of support for baic heakh care oriented todisease preendon, bealft promotion and simpl ca inteveos;(b) inppropriate resoure allocation; (c) poor and vaing opeangsandards and incentves; and (d) the absence of a demand-driven mechanismto enhance consmer power and competon.

3.2 Basic heah care, the base of the heah car pyramid, suffers fromlack of coherent and sained leadership, blurred gammatic identity andinsigcant resource allocato. Nuiion acdvities sffer from poortgeting and lack of teaton with health care. Special challenges are thewdely vaying ue o local health problems which require local souons;the total trnsfer of social sector re s, powers and resowurces to theprovinces; and the much weaker municipal capabilities (outside t largetcies) which make provincial a the major instrument forRefoIm. MSAS suport is required for settng national priorities andminimum stdards to enhae equity and effidency, as well as for prvidingoverall oversigt and perfomance evuation. Under the SSMTAL, severalanalyses are being cared out to imp!ve MSAS's organizaton andmanagement.

3.3 The lessom of past expience ud the lack of consisentysrg prvincial government politcal commitmen and financial supportDuTring the 1980s, a number of inovative peimet were canied out atthe loal and prvinl level, but failed to eicit major refonn becuse ofthe lack of broader poltcal consensus and sustained support. An example isthe cpitaon-based healt inace proposal made by the reres' i aeentity (PAM), which was tried out in the povinces of La Rioia, San Luisand Formosa, but was undermined by the oppion of OSs. negrated,autnomous public health area sevices (SAI4CS) intoduced in Misionesevenay faied for lack of poliical suot for the tansfer ofresponibiitis and porers from the prvince to the het areas, as well asby inadequate finacing.

3.4 More recny, major steps taken at the prvinc level are laying thebases for fthe i tonal and policy refm. Ihe pvins of Mendozaand Neuquen have opeati healt development plas. Neuquen,Jujuy, Salta and Mendoa ar reondening resource towards basic health care.

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Effors to reorganize hopitl car by blvs of cwoplexity are under way inCordoba, 8Woe, and IntroRi. Capitaton eystems, ae being ntodncdin Mendoza and Tocuman. SVal provincial fculties of medicie ae

vlewlng media tining t ricul and defing ways in which entry codbe egulatd in line with heith needs.

3.5 The ovarching goal of health policy should be the m vent Ofh sttu, wihn the edstnfg fnanci consftints, through better tgeinand mo¢e ei resource use. A fit step would be to develop a broadconseas on a few key nationa progrmmatic prrities and opeaonlguin and thento st a process of change based on t connsu withpolitil backing, ful pvider pa and appropriate budgetary andather resouce allocations in seected pwvinces and munlitis.

3.6 In the short run, the highest prority on grounds of equity anddefficiy is to adds the health and nutitonl needs of poor mothers andchildren his shoud be done by prgressvely improving the ecency andeffectivess of maternal and child care services. A successful, expandedmatemal md child care progam would open the way for reforms at higher,more co leves of care and in enire provincial healftf care sysems.

3.7 In the log nm, priot also has to be given to develop cost-efectver4proadhes to adult care. The prevalence of chrnic and degnenativediseases assocated with the aging of the popuon and the reaivdy highercost of interventions rated to uoe groups of diseases justify giving adukhalth cae a higer bog term piority. Impotant elements of te satgywould be: impwving lifestyles; a larger role for ambultory care and thefi level of It; rguled competition among pwviders; poolingof public and inance funding; and improved incentives, tn ency and

3.8 eler Devlopment. The isse is how to provide effoctivelymore ce health care, mttion and child developmenta tto presools under widely varying pwvincia and municia aneetThe prefable approach would define a ful package of tervnn, anddevelop ths irventn alog with eistmg services, squoted by staffincentves, and the picIpatin of mothrs.

B. Govermets Strate

3.9 A mber of steps being tae show Govement oitmet toreform. irst, a draft OS law, currnly under dicssiin Congress,would (a) give priority to financing a basic health care package of

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intevetos; (b) esablish cost paraneters; and (d) intoduce a nationalmodnioing process to measure provider performance.

3.10 Second, the tansfer of the maining naional hospitals to theIcI ts and provinces was completed in 1992 though the Budget law.

Today, provinces and a few large munices have full opemional andiancasp for heat cae delivery.

3.11 hIrd, nw drug regulaion opened the way for competition andfreed prices to move based on demand and upply conditions.

3.12 Foth, the analydcal base is being establshed for fue sectorreorms. With SSMTAL financing and technical assistance, studies are beingcaried out in the following high priority areas: (a) rs of theMSAS; (b) manpower use; (c) developig altnative provical o nand management models; (d) improving quality control of dnrgs andfoodstufs; (e) reidoing healt prmodon and diea preventon across abroad spectrum of interventions; and (f) estblishing a natonl healthmana infor n system.

3.13 The Govenment condrs urban health care development the highesprioritY. First, laer concentions of the poor, combned with easierphysical aces would permit greater impact of Govemment prgams inurban are. For example, about 1.5 million failmies or 5 mrHon poorpeople ie in 20-odd urban centes. Of these, about one hal or 2.5 milon(1.2 milion of whom are mothrs and children) are con ed in threemetopolitan areas: Buenos Aires, Rosario, and Tucuman. Second, urbanhealhc services have larger initial impl ng aacity and financingthn their rurl cou ats.

3.14 Governmet's sategy is geared to intrducing, first, a basic healthcare package of semrves for mothers and children; rapidly i ing thevolume and quity of sevices in the areas with the lrgt concentraion ofthe pow; g the tn of non-govmental o ion,such as the Chuch, UNICEF and local asscaton; and providing fedealfincing on a grant basis for developing MCHN progms.

3.15 The NaInad Matend and Child Heah Program. Recentde nts are opeing the way for deining policy opons and plans. InJuly, 1991 te President of the Republc made a persond commiment tomateral and child health and nri mprovement. At the same tme, theMSAS itoduced the National Mateal and Child Program (CompromiseNa_oIl A Favor de Ia Madre y d Nio, CNMN). The CNMNs broad

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objectve for this decade are to define and integrate MCH seni inambuloy and hospital health care, emphasize health promotion and diseasepvention and promote the parcipaton of famie and community growups.

3.16 The CNMN recommends actions aimed at: irmproving awarnssamong poliymakr and the genea public; stgtheing fede, provincialand nci commitment, and orienting manpower traiing andoiployment towards matemal and child health and nutrition; and Ipwvingmonitoring and evaluation capacity.

3.17 The CNMN provides a national political and progmmic phlaormfor deining and ealizig policies geed to develop integredmaternal and child health care and nutrition. However, the CNMN does notInch e ommend on how to improve the desg and delivery ofevies. The next step is the opeationaliztion of the CNMM at the

povincial and local level.

C. Available and Planned Resources for Matenal and Child Hlealth

3.18 The most important federal source of financing for developing MCHsvices is the MSAS's MCEHN budget. In 1992, MCEIN funds amounted toUS$133 million and included US$35 mmion for financing provincial milkpurcaes; and US$15 mil1ion for drug purchases. The balance of US$83milion was used for miscellaneous expendithres. is fund, alhough animpot ersion of federl government support for MCHN, is a weaklnstment for major impovement, since it lack prios, intratin withongoing ad projected provincial plans, and ac ity. The 1993allocation was increased to US$150 mlion, and is intended to providecouterp funding for more comprehensive future progmms, secflcallythe under the projecL

4. EMXTRNAL ASSISTANCE FOR THE SECTOR

A. Bank's Role and Assistance Strate

4.1 The Bank has been a strong suorter of the ambitious Argentnrfmo program. The Bank has asssted Govenment's efforts to stbiz theeconomy, libealize tade, samline fedel and provincialand pdvatize income-producing enterises. Thwghout this period the Bankhas emphasized the importance of complementawry investment focused on

* revtalizing social seices.

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4.2 Fmm 1985 to 1989, the Blank laid the pam ic basis for plyinga major social stor delopment role by caring out major stdi ofpoverty (Social Sectors in Crisis); population, health and nutrition(Populaton, Health and Nutrtion Sector Review); and educain (EducationSector Review). Ts was folowed by the ongoig US$45 miimo SociaSector Manament Technical Assisance Progam (SSMTAL, Loan 2984-AR) encompassng nine sectors and agencies. The recently concluded mid-tem project pe ace review showed that te proect is weeting and evenexeeding i a number of areas (abor, social secmity, social sectorexpditu) its policy development and nltunng goals. From 1990 to1992, in the field of heath, the Proguam provided the analytical basis forp ing the draft health insuc law and will develp, over the ast twoand a half yea of implen (1993 and 1994), in-depth stude as abasis for: (a) legislation to turn public hospitals into autonmous e ;(b) health manpower development (c) legislon freen drug impots andmarketing while allowing the sale of generic drugs; and (d) food and drug

4.3 In October 1990, and a the request of the th Fedead Secrar ofHealth, IBRD and IDB developed a joint health sector strtegy prlaimed at reforming health care provision and fiancing at the provinciallevd, niio c tin, and the introducion of perfor uadoutcome indicats and uniform traparency and accounabilt stanrds.The document was widely discssed in Argentina and helped promote keyeIements of a possible nationl health care development famework

4.4 In accordane with the Governmen's decision to trfer to theprovines the ns for social services delivery, the Baks CountryAssance Strategy for Aren supports improving provincia admuniipal heal services. Beginning with the proposed MCHN Project tohelp the provinces p e better health and nutiion assit to poormothrs and hldren (see pan. 5.2-5.5), Bank assistc would trgetvuleable groups in the uran poverty bets and the u ndedevloped nohempwsvinc, in close ion with provisncial Uwthonities, while continuingwith a parallel process of polcy and insuional reom at the nadonal andloca levels. The MCHN project would be followed by more comprregi projects, beginning with the Greater Buenos Aires region (wbere thelawgest conen n of poor exis), and later by sim projects in the poorNorthwest and Nothan provinc. It is expected that the proposed projctswould facilitate the inalization of health car delivery and flnancg.TsM strategy is suppored by ongoing public sector improvements inorganization, m_naement, aid finance being intoduced under the ProvdxinDevelopet Proect (Lo 3280-AR).

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B. The Role of Other Dow J

4.5 The role of exemal agecies in the social sects has been imited inthe absence of an agreed framework for social sector dv and apolcy agenda. Uuil reenty, lited eogition of te ofpoverty hndered giving gbg pnority to socal iss. negect wasrelnfoed in recent years by the urgency of addresing the crticalmac_-economic and institudonal problem boseing th conty.

4.6 As a resut, ex al agency programs ave of Hmited scope. TheUnited Nations Development Program (UNDP) and the Pan Amercan HealdOrganizin (PAHO/WHO) have been long imvolved n technical asnceprograms to the public sector at the federa lvel, as wefl as in providigadministive support to - c projects. Th iter AmcanDevelopment Bank (1DB) is statg to implem a healt proct with twomain components: the buidn of four provincial hospis and tecalassistane. UIJCEF is helping develop e suot services(iclding logistics and staff tainig fbr pwvinidal and municipalgovernmens and NGOs. The Italisn and Spah govements have lareand sti u bilateral nes of credit for geal puposes, icldfithe builn and equipping of hotals.

C. Lasons of E qrn

4.7 Since the proposed prqect would irpsent the frs free-stanighealth and nutrition operation in Arentna, the rview of £eraen coveed24 k-financed hath projects, as wel as 16 ntition prject in th formof SARs, PCRs and audit reports. The SSMTAL'A experience was also taken into accun

4.8 Factors which have affected health and nutriio ptojectimplemento are the following:

(a) Borrower cmmitment as manifesd by degre of support for poliyreorienta , sti-Vti_nal improvements, and budget allocato;

(b) ddschm for project preparation and Iniplementaioncontribe to the acanc on th part of peonnel at the differenlevels of the health system of impding semic rforms in thesector, and to the trining of local staff on resoumre alotondecisions and the b e pt pocesses needed toimplement loca subproJects;

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(c) the scale of project goals, usually lied to the dee of compxItyof project desg (especially relvant in the case of ual areas, whichhave very low absoptive paciy) ofte leadng to lack of focus andslow progress; problems are aggvated by coflicting goals;

(d) the choice of organization and nstucture: in balncing theadvantages and disadvantages of usig eaxsg strctr or newpre d o unts to manage prjec, expedence indictesthat prvided legal and araveato p sufficdintmanagement autonomy and flexibty, g adsting ageieSis the prefered optio to maximiwe political and 91fmcommitment, instiol development, and smooth erations,

(e) community involvement: the needs and priotes potenta sevceuse must be tk into account in project desg andimplementatn; community particiation is essenial forImprovingLegtimate sevce demand, pate fow up, outrach series, costrecovery, and field monoring;

(O) png, progammg, , budgetng and cash rlase mecnims mustbe relively simple, tanparent and easy to use;

(g) civil sevice or other relations must be flexie enough to permititoduing maaeet and staff icenie ted to pr i,quty and ; these incentves ar more difficult to provide forphysiian as compared to alied pwfessI staff and outeachagents; and for ruora areas as opposed to urban cens; enationicentives must be replcable to enir classes of staff, such as thoseassociated with basic health care, to ensure acceptbilY;

() thoough monitoring and evaluadton, beging with base surveysfrom the begianing of imple an, essenti to d oetneadequacy of process, output and impact; they requirecom_itment from the start;

(i) project desi must be feimble enough to adviablechag in scope, trget popation, procedue and componen; thisis partcully true for fit opeons in the country and for projectswith a naional coverage; mid-term revim with boad agendas arparticully helpful ¢ordenng pr4ects when suppog proacdwvsuevsion;

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() regar nution introns, a number of fctors werepaicularly helpful for succes imp tion and impac: (i) close

ntgrato with basic heath services, which quires rigawareness of health peonel; (i) tl;ting adequae enough not tomiss larg mbers of the needy and to avoid wast, while notexcessively fhneumed to lead to ad i ve gddlock, or to exclude

prevention; (ii) stog emhasis on nutrton education,which has proven by itself capable of improving nauiton stas, andon growth monitoring with sg matea involvement; (iv)provision of spplenl foods which closely match ordinary diet ofthe poor, which cover mothers as well as children, and which promotedemand for the entire packge of healt services; (v) extensive use ofmedia campaigns; and (vi) includon of m ent suplemeio

4.9 The SSMTAL mid-tam pro ce rview has povidod vauablessons of expedence in the social secton in AgntinL The most imortat

concem the need for government ownership; few, focused obtecves; careflas f tass, implemeAIon and capaies; and

imroement as opposed to radical change.

S. THE PROJECT

A. Project Orign

5.1 Te propo project was identifd in mid-1990 as an emergenyion to alleviate the effects on the poor of the Germent's aus y

progm. Prject preparaton, however, dd not progress becase theGovaement's initial emphasis focussed on resolvin criea economic issuesfacing the country (which postponed acdon on the social frn) and the weak

I e and operinal capacity of social sctor agencies. As thepedod of emegency was superseded by the rsmpin of economic growth,the project proposal was reoiented to isfy the unmet heat and nutritionneeds of mothers and childn, as well as to promote early childooddevelopment at the provincial and munici levels. In August, 1991, theMSAS reested UMCEP assitance to parep the prqject A teamorganed, recruited, and managed by UMCEF, in comsultation with theMSAS and the Bank, prpard the project proposal doing the December1991-December 1992 period with SSMTAL financiAg. The Bank made twopreParation visits, one in July, 1992, and another in October/November,1992. Appraial took place in March 1993. Negoations took place inWashio, D.C. on June 8-10, 1993.

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B. Project Objectives, Rasdona StrateU and Area

5.2 Project Objectives. The proosed project constitutes the first stageof the Govements National MCEN Progmam, wbich has wide publicsuppor and the personal mmime f the Preident of tie Republic. Tbeproject s desgned to asst the Govenmet in Impoving th bath andnutritional status of poor mothers and children (as defined by Census dataand periodic household surveys) and promoting compr care anddevelopment of preschoolers in p ating pv and muni sacross the county. The project would also supo the Govenment'songoing effos to decentalze socal service m and fiancing,taldng it one step frther from the provinces to the ms. Iheproect would be carully targeted, and would promozt efficiency andsevice qualW improvemens estg maternal and child health andnurition, and early childhood development progams. More specifically, itwould:

(a) sengthen maternal and child health and nutrition, as well as childdeveopment proms by supportng the delivery of basic bealth andnutrition and early childhood development service packages orentedto health promoion, disea prvention, simple cuative care, andpsycho-social and ineectual chld developent;

(b) improve the oranization and management of public institutions andcommuniy or ations involved in the delivery of maternal andchild health and non, as wel as early childhood developmentprogams; and

(c) support the decent li of decisons and mamet byddelting to parang provinces and municipalites the analysis ofneeds, as wel as tie p mming and utili of financing forstrengthening maternal and child health and nutrition, and ealychldhood development progams in their respective jursdictions.

5.3 Rationale for Bank Involvement. The proposed project, the Bank'sfirst free-standing ivestment lending oation in the heath and nutdtion,and eady childhood development sectors in Argentin, is in line with theGovermen's and the Bank's stategy of worting human resourcedevelpment and poverty alviatin in the couy by improving the delveof so8idal srVcs (see pam. 4.4). The project would inie a process ofexpanded cover and efficiency improvements in the delvery Of socialservices which are at the core of the Govament's follow-p strategy toclement ongoing economic and public sector rdorm programs. The

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proect would enable the Govement to ntegmte, further develop, andrepcate on a wider scale locl ittves, ncdng NGOs and communitypartcipatio, wbich have attained limited succes In the past becas of lackof political support and resources.

5.4 Project Stratea. Owing to th wie variety of local conditions theproject is designed to provide maimum operating flexibility. the projectwould permit adapting basic services to local conditions, while promotingexpermentation, feeack, and application of the lessomns leared. Tagetingwould enhance impact at the lowest cost. Within each partitg p ce,municipal subprojects would be ipend over a thre-year period phasedover the project's six-year life.

5.5 Project Areas. The proposed proect would opete at two levels.First, investments for basic health and nutrition servce, including childdelivery in maternty wards of local hospitals, and preschool developmentcenters would be made n selected low-income munc es. At theinstit l level, tchnical assistance for the pepon and implementtionof provincal and municipal subprojects to be pwvided though the ProjectCoordination Unit (PCU), m _t and te l taining, stgtof infomation systems, eduamtion, information and communication stratees,and sudies would beneft the overl pwvinc health cae systems. Studiesand pilot experimts wod help dewlop knowle and opdons, and testaterave policies, orapnizaio modalities, and incentive sysems. Up to 16mucipaliies in 6 provinces (Buenos Aires, Cordoba, ntre Rios, Mendoza,

Santa Fe, and Tucuman) would participate in the project on the basis ofpedefined selection criteria (see pax. 7.9 and Annex C). The averagemunicipal subproject size would be about US$16 million. Funds not used byexecuting municis would be transferred to otber m lites in thepariciatig provinces. The first three pwvincal investment prposals(comprising a taget poaion of about 160,000 mothers and children underthe age of 6 years, or almost 6 percent of the estmated total of poor mothsand chi under the age of 6 years in urban areas of the country) havebeen selected and are in differn stages of proceing their subprojectproposa's (paa. 7.26). The esmaed total beneficiary population -low-income mothers and children under the age of 6 years in the six proinces ofthe project- is aximately 500,000, or 20 percent of the esmated total ofpoor mothers and children under the age of 6 years in urban areas of thecountry. A second project might be prepared in 1994 depending on projectperforance and additional demand by provics (see parn. 5.39).

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C. Man Featur of the Project

5.6 The proposed proect would pave the way for stablishing pimalyhedth care as tie main prioriy of the publc health sector In Arentinabegng with mothe and cidrn, and for urnng adsting infant feedngceate into cmprehensiVe chi deveopment sorvices. The project wouldbe orented to healt promoton and dise preventon, Inclig outeachactvities geared to early detcdon and trtment of groups at risk, as well aseauly chilhood development. The family would be the basic uni to betaged to enhance the impact of muftay riforcing hea ntrtion, andducation interveons on the overa saus of individiad membeas.

5.7 The prect would coist of te components. Tbe first is amaterPal ad lchid health and nutrton component that would stengthathe oraa and resouce use for delivering a packge of basic health andnutrton services argeted on mothers and chidre. The second, an earyildhood develomt component, wou support the ins on f

a new model Of eense physical, mental, and socidal development ofprschoolers. The third component, aimed at tinal s,would spo the vement of pla g and mme acity Osices and the development of more ratonal policies reled to mothersad cildre 5

D. Detaed Project Description

1: Maternl and Cid Healt and Nutrition (see TechilAnnes Cl and C2 In the Project's Working Mile).

5.8 The bsc pacwk of services (Anes Cl and C2 in the Prqject'sWorkig Pile) consists of: (a) wom's reproductive and cild health care;

) food supplemeion for undernoudshed pregnt women and childreanunder 6 yeas of age, as well as for lactg mothers; and (c) health andnutrto educaon and prmoin MThe project would finance, as neeqssay,the expasion, refiing, equipping or eeipping of existing healthf ties, birig addiional staff to complmet existing health and

teams when saff rdeploymen is nOt feasible, purhasngeic dpugs included in a basic drug list and other medical swpplies, andpuhasing food splements. Funds would also be alocatd for stffsuervi, maintenance, and health and nt educatin and promotion,

inudng conmmunityr paricpaton

5.9 The women's reproducthealth care program would concentreon: pre-nat contls, incuding nutition surveillae of pregan women

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ad detectdi of possible gestadon and delivery complications, tetnusvaccintion, child delivery, and post-partum care;bteastfeeding promodon; family planning; conol of sexually transmitteddiseass; ad cervical cancer screenng. The dcld health care prosrmwold help reduce cldld mortality and morbiaity tbrough actions such asinfat care, growth monitoring, bresd promotion, vacinai aainstmeasles, diphtheria, pertssis, and polo, oral rehydaio terapy, preventonand eauiy tratment of gastroinestna and acute resp y diseases, as wellas ijury control and teatment

5.10 Thesupp a feeding prom would reforce the impact ofhealth-reed interveons on the twin problems of poor healfth andmalnutiti among children under six yean of age and pregant andlactang mothers. This program would be a key instrument for attmg thepopulation to preventive services and attempt to rehabilitate malnoedchildren and mothers. Tarting of curntly malnourished individuals with aspecialyreinforced food lemeon scheme would be done thrwgh awelldened progam to monitor weight changes during pregancy andchildhood in local health facilities (see Technical Annex C2 in the Project'sWoring File). In addition, breast-feeding psctc would be monitored toalcate food supplements to lactatng women. Growth mitoring norms ofthe Argetne Pediatrics Society would be used to detect malnutriton amongchildren cner 6 years of age, and the Rosso-Madones nomi would be usedto identify malnutition among pregnant women. Estimated underweightpevalence ;n pregant women (weight/height) and chden (weight/age) Ison average about 20 percent. Once ideifed, tgeted individuals woudreceive food supplements and nuition education; upon recovery fwom

Ianui beneficiaries would be phased out of the food suplementionprogr based on health personnel evaluations. Appropriate basfeedigpacc woud be rewarded by delivering sl tary food. Redingmic upplementtion, malnouhd inns under one year of agewould receive an iron-fortified milk formula; other micronutuents up to RDAwould be also considered (Ca, Zn, and vitamins A, C, and D). Iln addcidon,iron and vtmin C tablets woud be disibuted to all prgna women. Foodsupplmenan, inluding micronu-, would be provided to projectbeneficaie at local health facilits according to a progmmd schedule ofhealt checkups. The mix of food produt to be disud under the foodsuppent progam is based on a baaned contribution of nutriens,which is in line with the country's nutidonal habits. It woud not affectnegatively b ding duon because the food products to be distutedin the first six months post-partum would only be deliveted to curentylcang women. In additon, tb- composition and cost of the food pkages

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was defined to tale into account intra-family redisibution of food sffs, andthe fincial ustinability of the tawgeted food supplementtion program.

S.11 The heal and nutriion education and promoton program wouldprovide Information, cadon, and mm on about prenal care,brfeedig and infant feeding, dietay qualiy, hygiene, fmUily plag,seually tansmined diseases, environmental health risk, and injuryprevention. The objective of this progrm would be to improve healh andnutritional pracices among the general populon, particuy changingbehaviors, and to prevent the onset of illness and disea. To this end, theprect would support traiing for health pasonel so that ey dissemateeffectively heath and nutrion messages, and the development of hath andutdtion-related messages and materials, inchluing mass media campaigns

(see paras. 5.285.30).

5.12 OrgnIon of the Deivery of MCEN Package. The basicpackag of maen-a and cbild health anc nutrition services would bedelivered through an improved network of axsting health centes andmaternity wards of local hospitls. In those areas where exstng hospitalsare handlng over 10,000 deliveries per year, a figure well aboveinternata standards, additional maternity wards would be establshed inthe faciities currendly without them in order to relieve cogestion in themain hspital. Typicaly, the basic package of MCHN services would beoffered in health centers covering on avepage between 5,000 and 10,000resdents, and in maternity wards of hospitals atendig on average between2,000 and 5,000 child deliveries per year. The project would promote theestablishment of a referral system based on local heakh servicewihin well-defined geographic ars. To help ope lke the referalprocess and ensure condnuity of care at the local level, te use of two newinsrments would be promoted: the first, a peinatal cae card (carn6perhnata), for pmmin regular check-ups and viss to health facion the bads of detected hea and nutitional needs of prat women; andthe second, a heakh card (cam6 de salud), for moniong heath andnutrition saus of childen under 6 years of age, and p aming a scheduleof visits to health facilities. Under this system health cears would becomethe entry point to the local MCHN service delivery network by providingpro-natal care to pren t women, and would rer patens to hospitals witb

bsr and neonatal units for child delivery. After delivery, motes andchildren would be referred back to the health center where they wouldreceive post-pattum care and nutrition education and prmoton, partcularyfor improving breast-feeding and infant feeding praces, and periodicgrowth monitoing check-ups and vaccinations, respectively. Healthpersonnel would also undertak outreach activities (e.g., home visits would

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be conducted to det those project bfaling to attend theirsded visits to health fcildties and motivate them to do so). Local healthservice a-rangements and thoeation of Iefrals woud vaty according topopuation distributio and is cha s , rritodal bounes, andecisting access to health fcilis, incuding their number and the complextyof services offered.

5.13 mprovement of Health Service Network. The project wouldaddre the physi, technological, and optionl dedcncies plguingArgentine MCHN service delivery. In each province/municipality, theproject wold spo the e tatIon and pgrading of exsting healthfaces over a three year period. Investments would be made to cover thegaps idntified by needs assessments (which would be icuded in theprovincial/municipal investent requests) based on the IequirIments of thenew MCHN modeL Priority would be given to imroe hea f andto cover the populton in under-served communities. Efforts would inludephysical plant and equipment upgading, imprving staff mix, taining forexsting and new staff, and s ng p mming, montoring,spevsion, suply, and ma nce. Te refenal network would beestabshed based on sd ed norms and procedures; anual plans wouldbe prpred; social comction acves would be initiated to informlocacommunite about project objectives and start-up activities and to enlt

ii n; and ep ologil and srvie daft would be collectedand anyzed by provws and prvincal/municipal health authodi-e. ITedelivery of health and nutrition intvenions included in the basic MCHNpackae would begn during the first year of subproject impleIn. the second year, intrsectoral lnka would be promoted, pardcury wihpreschool progams and community o ins. Community outachadviis would be initiab d, incudg heakh andn on educaion andpromoto; prommic and patio al a4ustments In the model would bemade according to e logica and health service data colected in eachjursdicton during the first year of subprqject im pl

Component 2: Early Childhood Development Componet (see TechclAnnm D in the Project's Working U.).

5.14 Differet county experies bave donsted that early cdevopment progms, together with health and nution services, posivelyhfluece children's development and readie for school, as weR as their

scholastic performance. The aim of this component would be to: (a) supportthe gowth and devdopment of childen between the ages of 2 and 5 years;() promote com ehi care, and reorgnize esting progm; and

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(c) facihtate the incorpomdon of women into the labor market by providingchild care. Feedig progams for chldten (comedores Infanties) and

ndergarts into child developmett centers (CDCs) will improve nutritionand psychosocial stt in succemive stages. CDCs would follow a serviceschedule of up to 12 bours divided into two shifts of sixhours each, with amaxdmum capacity of 100 chidren per shft. The CDCs schedule may beexnded for children with woing mothers. Care for these children wouldbe provided by mothers in the cmmunity under the supervision of CDCstaff.

S.15 TrAing would be provided for staff in the management andimplementation of social progams and for teachers and mothers in charge ofthe centers in the subsve aspects of the program, so that teachers developeardy childhood educato acdvities and mothers may take on the functions ofcommuit educational promoter. Education materals and toys would berocued, and equipent wod be prvded for impoving cooking, fooddistribution, and educational services as needed. ITe above activities wouldbe financed by the prqject except meals, which would continue to be financedunder exst federal and prvincal a ents.

5.16 Active family and commufity paicipation would be promoted tospport CDCs' activiies Voluteer mothers engaged in the implmentationof daffy activiies would compie the CDCs' core support group (grupopromotor inial), which would be respible for basic management tasks.A second group comprised of parets and nighbors would be established tospport the work of volntee mothers. Additionally, to mobilize support ofthe communky at lawe, a m emt group (comte de gestin) comprisedof CDCs' staff and rprseivs of NGOs and local governments would becreated.

5.17 Fiancing would be available to pay volunteer mothers who care forthe children; it would be adminierd by groups of parents and neighbors.Small financial contreiutions from parents as well from public sector andcommunity insitions would be collected.

5.18 Iniis prry would be given to languae development, laterincorporng psychosocial development. Teachers, provided by proviniand muniipal sources and taied according to agreed workshops (see AnneEl), wtould be placed in preschool feeding centrs, where no educationalactivites are carried out at preseu Provinces and muniplties wouldfinance teacher salaries. CDC teachers would provide in-service tring formothers and undertakes the initial work of motvating the child.Educatinal acthivties developed by professional educaton staff would be

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incorporaed gradually. n addition, education tehndians (one for every 10CDCs) would be provided by mu ties to swppot implm ptato ofprogram activities. Ihe CDCs wou'I also have community educadoncoordinat and promoters, who would be selected among the mothes whowork in te centers.

5.19 The CDCs would opeate i cordintion with health centers. Toenter a CDC, each child must have a health cad issued by the health center.Grwth moniting would be done each semester by local healft center staffMalnourished dan sick chidren detected at the CDCs would be referWed tohealt faties, and heat and nutrition educatn actvit would beorazed. Outreach actividtes to households and the commus would becanried out to strgten the linges wi famies d counitiespatlaldy for the gemen and operaon of the CDCs. Tiis is a keyfeature of the CDCs that would help suain the progrms.

Component 3: Inst l Strengtheng (soe Techical Annxes El, EZ:,E3. E4 In the Project's Working e).

5.20 This component would enhance long-term capacity for ptanning,managi, and implementing mother and chld-rlated activies under fivemajor subcomponents: (a) trning; (b) infmadon sstms; (c) socialcommunication; (d) tecbncal assistance for reognizing school feeding(comedor escolao ) programs; and (e) studies, includng the pxp=tionof a second project.

5.21 Trainn (see Tecical Annex El in the ProJect's Workng Ell).The objectives are to improve eficency and quality of sevice delivery.Health and nutrition personnel, ki n teahe, and mothers who workin prschool centers would be Involved. Most of these are the lowest paidpublic sera, have no ientives, and have seen a mard deterortionintheir woking conditions. In parcular, the moters who work in preschoolcenters do so volunty, and in most cases, povide serves iregary andwithout a ty. The sipecif goals under this sbcompt ae to:(i) upgrade the knowledge and dklls of healtih and utrition personnel, bothdinisttve and technical; (H) improve teching capabsii of prschool

personnel and of mothe who work in CDCs; (ih) improve efficieny andeficacy, with special emphais on pOg g, ma, andmonhoring of project activities across the board; and (iv) improvinterectom d coordon of heal, nutrition, and education services.

5.22 Trining would be canied out through courses, seminars, andworkshps. Trining would involve: (i actviies aimed at ensung

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adequate prqearon and start-up of proect activities; (ii) managementacdvites to reinforce the adm ve capacity of personnel involved in thproject; and (O) in-service traing for providing knowledge and kmsneeded for Vpacific tak. PCU staff would train the taners. In theworkshops the tak are to defne agreement, coordinate acon, andevalue the Imleme of project activities. In courses and seminarsndes and procedures would be defined or reviewed, and knowledge updated.Basic audiovisual equipment would be provied, and documeon cenutswould be egthened.

5.23 Iformation System (see Techdical Annex E2 In the ProjectsWorkig fle). An hitegted project informaton system (SIP) would beestablished at the naional, provincial, and servce delvery unit levels. Thebasic SIP would inchlde tre substems: () adminisve and finace; (u)project m ent; and (iii) srice delivery monioring. At the nationallevel sytem resonsibilities would inclhde nonnative, technical assistance,and Ihmited development funcdons (e.g.), dvelopment of data entry modulesfor the monoring subsystem to be istalled in seice poder unis). Atthe provincial level, responsibilities would emphasize development,operton, and thnical assisUce functons.

5.24 The adminIstrative and finance information subsystm (AFIS)would be developed to SUpPOrt the accountig, finance, and budgeigfunctions of the project. Adminive procedure mamnals have beendeveloped for each of these functions detailing the methods and reqirementsfor managing the projects funds at the nadonal, pwvinial and servicedelivery levels. The APIS would provide information with which the projetbudgets can be efectively programmed in terms of project componet,function, source of funds, and budget lne Items witmin the aPProPnateaotted tme periods. At the national level, the AFIS would suot projectfunding approval, diusement and expend , monitoring and evaluaton.At the provincial level, the APIS would supt the same funcdons as at thenatonal level, but with less emphasis in evaluatn and more emphais ondetailed accouting and monioring of specific exdures. The APIS wouldbe compatible with the monitoring infmati subsystem. The projectwould requr computer equipment for the development and opaion ofaccounting, budget, personnel, inventory and other computerized modules atthe naional lvel. At the provincia l, automation of these moduleswould depend on the specific r s identified in each of the provincialprposals. At both the provincial and nadol levels, the AIS wouldsupport the preparton of a series of reporu based on key indicators (e.g.,stas of accounts, proammed budget line item disurements, purchasesmade, contra xecuted, inventory sta, peronnllpayoll data).

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5.25 The project me InOrmatiOn subsytem (PMIS) wouldassist in the p g, paning, and eet of project actvites.At the naional leve, the emphasi woud be on ovea project anagemenassessment At the proviil level the emphasis would be on projectaexetin, permance and prductivity assessment. Integrting the resultsof inmation developed by both the monitoring and the adminive andfinanice subsystems into execudve summay indicators (denominated "tablerode comando onrgnizaclon') would be a major goal. Tcking overall projectprogress would be developed using standard methods such as GANTT charts,project management software packges, and custom-tailored tools that allowmonitoring o activity/task once, implemen delays, expenditueproblems, and other botlenecks. Evaling oect mance and impact,plus speci stud woud be cried out sepatey based in part on thoupus from the PMIS and the SIP.

5.26 The seric. delvery monorg subsstm (SDMIS) would tackImplementatn of proect activi and programs. This subsystem would

resoure ut in, process pefo e, and outcome indicatosfor each component, differentiating between those that corresond to each ofthe decision-making and opeion levls. The informaton that is to becolected would not burden xcessively health ciities and CDCs personneLTh monitoring subsystem woldd be flexible enough to accommodate thediferences between the exist data prceig systms in the pwrvinces.The SDMIS would be organized according to the requiement of the dfferetoperatia level. The managers of the SIP at the naiona and provincalevels would have the on li for managing the monitg subsystem.Implemeing fthe SDMIS would require woing closely with the provincesto prevent incompat of monitoring inforation betwee and across thediffn opaid lovels. At the naional levl, the emphasis would be onmont the overall progress of pect implementaion inthe p ,and ensurig adequate moniodng capabies of provinces and sevicedelivery units. At twe provda level, monit0rig resonsibilities wouldempsiz progres evalon. At the municipal service delivery level,monitorig would be pefomed by staff at each heath fil.

5.27 Techical assistance would be pwvided for the design, development,implemenion, and maitnane of the SIP. Computer hardware andsofware would compment avaible equipment; staff traning; and thehirg of tec l peonnel for data collectio and pcessng. Uponcomplet of the system, the data prceing centers would benehonected for the distribtion and srig of monitoig data Computer

system conslants would be hired to assist in procu , provide cnicalsupr in e iacqusion prmcess, in equipme intalation, and software

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development. The project would try to ene effective access to technicalass_stac by computer users for opeaton and mainteace. Individualconsultants, maIntenanct and tecical assistance coacts witi vendors,and/or l ning of peonnel would be financed.

5.28 Socdal C n i (see Technial Anex E3 In the Proje'sWorking File). The objectives are to: (i) create an awareness of socialpriores that ge tes commitment and soidar so as to fostr thedevelopment of prqject acdviies; (ii) promote the various progams involved;(iii) develop a network of alliances among istions, servie pvider, andthe community; and (lv) disseminate information about project objectives and

5.29 The education, infomation, and cation acvities to bespported under the project would vary accorig to the geogmaphical andsocial chaI ccs of picping provinces and municipalties. Theseactivities would be diected to three groups: (i) leades; (i) seproviders; and (ih) beneciaries.

5.30 The project would allocate resoures for hiring public relations firnsto produce the mateias needed, both graphics and audiovisuals. Radio,telvisin, newswpers and magzines, public thoroges, and publictrsportation media would be used.

5.31 Technical Asistance for Reonng School Feeding Programs(see Tedial Annex E4 In the Project's Working FSle). Reshaping andbetter tageting school feeding progms would be promoted because of theirlre size. These programs are financed by the provicial governments, andin 1992 spent US$170 mMion in food purchases alone.

5.32 Provinca tipon under the project would requr a commitmentto rgnize the school feeding progrms. The project would fianetechoal assistance for man ement, dmiron ofkitchen and cateia servic, ad design and suervisio of diets andmenus. Nutrtional tetng instruments would be developed. The mainobjetiedve of this subcompont is to improve the overall efficiency andefetivenes of the school feeding programs to free up resources that theprvins can redect to other soc pros, while also imoving itsefecdvens.

5.33 Stude. The poject would sot pol;cy and lst o chagsin the long-mn for the deliver of MCHN and eady childhood devepmentservices by fincng dies on prioity i . The stdies suboomponent

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consists of: (i) three nation-wide studies to be a ed direcdy by PCUstaff: a national nutrition survey, evaluation of natonal food spplemenprogram, and the project impact evaluation study (see Action Plan, AnnexA); and (ii) short-term stuies on issues related to the organizaton ndmanagemnAt of MAIN services and early childhood development progrmsto be inlded in the provincial investment subproject proposals.

5.34 Natona Nutrition Survey (see Technical Annex Fl In the Project'sWorking ile). Due to the scant information available on nutritional status,a National Nutriton Survey would be undertaken under the project. Teprposed smvey would be a basic step needed to pe , for the frs dme inArgenn, a national food and numtrition policy. The survey wouldconcentrate on mothers and children under six years of age. In addition tothe usual nutriona status measurements, the survey would consider .colleion of other variables (socio-economic, cultual, access to health anduition services, brafeing prctices, preschool care, and

enviromental. The foRowing aspects would be studied through themeasurement of biological indicators in the matemn and child populon:an _t (weight and height, and probably skinfolds thickness),hematology (study of iron, folic acid and Vitamin B12 deficient anaemia),Vtamin A deficits (serum retinol), Vitamins B1, B2, and possly B6deicits, deficit of other minerals (Ca, I), and paraitology (probably only

ough efaces examinin). Regarding the rprsetveness of thesamples where the above mentioned biological vaiables would be studied,two types of designs are considered. Only antrpometry would be sudiedwhen using samples with provincial representativeness. In those samples,divided in sub-samples aimed to include the poor (population with unmetbasic needs) and non- poor groups, the folowing additional ables wouldbe stued at the family level: socio-economic, environmentl, frequentilnesses, access to health servies (including immunizats and prental carecoverage), and parcipation in preschool programs. Representve sub-samples of nine regions of the country would be drawn, also with dueconsideraton to poor and non poor groups. In those famile, studies of thediet (through a 24 hour recall survey), breastfeeding habits. miruientthrough biochemical determinations and possibly pasitology tbrough faecesexaminaion would be caied out. The survey would be conducted dringthe first three years of project implme ton. Initial survey proposal is inthe project files.

5.35 Ipact Evaluation Studies (see Technical Annex F2 In theProject's Working fle). The impact of health and nutrition interventionsoffered under the project would be evaluated using a before-after design.This design was proposed because altenaive experimental designs are not

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adequate for drawing conclusions about the impact of project intenonsbecause etbical consideions prohibit leaving a randomly assigned controlgroup without access to project interventions. On the other hand, theepeted diversity of poor groups and the various interventions that can beunderaken simultaneously in the country do not permit defiidon of a trulycompamble control group as with a quasi-experimental design. Ipactaluadon of project activties, therefore, must allow for all other possible

known influences that can affect project outcomes. As a rsult, a ter1calmodel of posible outside influences would be constncted to identify glevanindependet variables. Multivariate techniques woud be used to adjust forthe efects of independent variables 4hat may vary by year of compason.Baseline data would be collected during the first year of the project for theevaluadon of imact. These data would later be compared with thse of theintervention period during the third year of project implementat0n. Daftwould be obined from two sources: (i) household surveys; and(ii) infonnation gathered at health facgiies and CDCs. The latter is part ofthe monoring system that surveys health and nutrition indiators andactvides as a regular activity of the health personnel.

5.36 To assess the impact of early childhood interventions supported underthe project, an evaluadon would be undertaken of processes and resuls at the

prticptin-g CDCs. Monitoring would be performed every sx montsproject completion. The impact on the development of cidren

ateding the CDCs would be evaluated two years after the progrm isinitted and cildren's perfonnance would be evallated at the end of thefirst and second gade of prmy school. The evaluation would focus onmeasures such as school repetition rates, drop-out rates, and overallscholastic perfomance. Cohorts of children would be selected beforehandand would constute a reprsentative sample of programs at diffrent levelsof develoment within a variety of insttutional conteXt. Iitial impactevluatdon proposals are in the project files.

5.37 Evalaion of National Food Supplementation Progm (seTehnical Annex F3 il the Project's Working ml.). The objective of thestdy would be to evaluate ong programs and recommend refom in asample of tin provinces. The study would assess possibleimprovements in the progam's targedng, product mix, service delvery,management, and proement methods. It would idefy legl, shtuctural,organiztional, and adminis ve mocaons, as well as resouies neededto implement proposed reforms. Tbe terms of reference for this study wouldbe discussed during appaisal. The study is expected to be completed by theproect's mid-term review.

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5.38 Other Studies. The project would also finance short-tam stdiesfocusing on issues related to the organizaton and delivery of MCHN adearly childhood development servces at the pvincal vel. Specific aeof study in each of these topics would be fombulaed by participAtinprvinces and munipaes oding to their svide y needs withthe goal of futher impving the rgtion, m gemet, delvery, andfinancing of the above menioned services.

5.39 Technical AssistanceiTftparation of a Seond Project. Iheproject's completion date would be June 30, 1999. Duingtechnical assistance would be provided to provinces not partcipating in theproject to help them prepare subprojects for inclusion under a poile secondMCHN project, and, more generaly, to help address key elements ofimproved resource use in the MCEHN area. Prelminary emts indicaetht a second project might amount to US$150 milion equivalent, and wouldincude additional municities in the six provinces already pa tipa inthe first project, as well as oher provinces that comply with the agreedprovincial participation criteria.

6. ESTINATED COSTS AND FINANCING PLAN

A. Costs

6.1 The total cost of te project is esmated at US$160 million, with aforeign exchange component estmatd at US$6.4 mMion, or 4 percent oftotal project cost. Project costs by component are ummized below inTable 6.1. Deailed costs are available only for the PCU, the nationstudi, and the frst subproject to be pin the Florencio VareaMuncipality of the province of Buenos Aires, which were evalated by thePCU and the Bank at the time of appraisal (see Annex B). Over 80 percentof total project costs would be allocaed to subpres.

6.2 The cost of civil works was estmated globally on the basis of healthfaces' bilitation needs and uni costs takn from stdies made by thePCU and eia_tes from Florencio Varela subproject. Equipment andmatials costs were estimated on the basis of unit costs per healt cenr,and an estmated nber of heat cen per 1,000 inmetropoltan areas. Esimates for technical atace are based on marktrates for loc ' and ional consu. Training, salas, t velallowances, and other operating costs are based on averages for a sample ofpotenay patici g jrisdions.

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Tab 6.1: ARGENTNA- MCDIN HROJECEtmated Preet Costs

(US$ '000)

Local Prg Tol S Fo*n % ofExhag Bao .

PNo l and Muica Subpwjeft

1Forno Varda 5,117 219 5,336 4 4

Fuu Sprqjeos 111,704 6,050 117,7S4 S 78

SbtDtAl 116,821 69 123,091 5 82

Natel Nuion Suvqw 5,630 0 5,630 0 4

P9ujc Ic Evaluaton 1,930 0 1,930 C 1

Skim and Autng 1,487 0 1,487 0 1

_o___Comm _n ___do __C____ _ 4,000 0 4,000 0 3

T*ecL Aseo oe for Inb Dewalop. 4,000 0 4,000 0 3

PCUaI _ _ __=

Peao ni 8,825 0 8,825 0 6

Teuoul A____u _ 650 0 650 0 0

T_ wand PurdeM S14 I 0 514 0 0

Conapus. Equipmet and Software 0 7____ 73 100 0

Office Ma_tra NW Savie 359 0 359 0 0

SubtA 10,347 73 10,420 1 7

TOTAL BASE COST 144,215 6,342 150,557 4 100

Physicaouugmaia 838 13 _5 I

PNic C 8,583 9 8,592 6

TOTAL PROJECT COST 153,635 6,365 160,000

a/ PM Staff would perfom varo tasks (1 meOf ovem. pojecIII it i dDn; (iQ prov ision of wbdcd aulam In th p Fpato and

imiet-entain of provinci and municia s roets; (ii) review andevabation of p incia and mu ipa subpoctp s; and(v) met of n dationa tudu ds and c s.

6.3 Con gc Albowance. Prvision for price and physcalconti -i bnce has bee lmited to the istitutonal component, which consists

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of discte elemeats and for Florenco Varela subpoject components. Localcost price coningencies are based on an annual infl rte cf 12 percentfor the 1993-98 period.

6.4 Duties and Tax1. Locly procured and importd goods necessaryfor the project are exempt from the valueadded tax (i.e., to the extnt thatpublic initudions patcipating in the project are the final consumers, a

on of the full amount of the tax is not possible) and the customstax. Taxes as ted with personnel income are equivalent to 33 percent ofgross sabries and amount to about US$6 mmin.

B. Thuandng Pan

6.5 Ie Bank loan of US$100 milion would fia 65 percent of thetotal project cost net of duties and taxes (see Table 6.2). The Goverment ofArgentn would fiance US$40 million which rprsents 25 percent of thetotal cost of the project inchdag taxes and duties. The pwvindd admunicipal governments' total oibutions to the proect would amount toabout US$20 millio. Both die Bans and the Fedad Goverment'scontributns would be tansferred to the pa g provinces as grants.

6.6 The project would provide retoactive financing of up to US$10mimlin (ten percent of the prposed oan) for expendi incured afterFruary 1, 1993. Rtoacdve fiancng would allow the estblishent ofthe Natonal Project Cooli Unit, start up activiies of the FPoencioVarela subproject, of the pwvincial and municipal executingunits, payig saries of key ddt onal staff, legislative andI inistivework in the provinces, logistics, and developing information t.

6.7 Based on regularly updated investment plans, the Pederal Governmentwould allocate funds in the MSAS budget for each year during the six-yearproject impl en perd. Par provinca and munpalgovernmens would allocate resources in a smiar way to fimance thdir shareof incremental recurrent expendis such as salaries, drugs, and food. ITefirt fedeal govment allocon of US$10 milion has been made inMSAS's budget for 1993 (pam7.25). During ns amuraces weoeobtaned that the Govnment would not later ta Octobe 1 of eachyea during the oexuon of the Project, sub_it to the Bank for appovalthe hwI tnt plan for project activiieo, Including thnialallaio, during the net sucding year (par. 9.a).

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Tabl 6.2: FlIANCING PLANa toa

i ___________________ __________ _______ _ F in a ncing _Totl Projpet Imm IoveRDM Pravinu

PCU 15,202 15,202National Nutrtio SurvY 7,S62 7,562

Projet Ict Evuatn, 2,815 2,815 _

Studios, Audits & Tbb Asst. 1,487 1,467

Social Con 4,000 4,000

Tech. AssisL for Ins. Deveop 4,000 4,000

Floencio Varda Sbpipojoet

staff Saaries ki 1,768 0 1,097 671Thugs 959 0 613 346Food 1,188 0 711 477Infastiuctu 1,599 1,599 0 0Euipen _t 697 S42 90 65Vehicle 95 95 0 0Treinlng 450 450 0 0Techtical AuEis nxe 423 423 0 0

FuUre Provincd/unickwdSubprOecta_ _ _ _ _ _ _ _

Staff Salarias / 32,644 0 23,554 9,090Drugs 14,948 0 8,676 6,272Food 8,331 0 5,258 3,079Infastructume 42,607 42,607

Equlpnsent 13,683 13,683 0 0-Vebicls 648 648

Training 3,642 3,642

Technical Asudlscso 1,24S 1,245

Iie Taljc Co W 160,000 100,000 40,000 20,000Al Totumay nt tadd Sto braoUn*.i bInludes toxs ad MOtway Incentves fstaff tinig and bomues for chUd d pelposmt cents'

auxiliaty peonndL

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C. Recurrent Costs and Susbiity

6.8 Incremental recurent expendiues would be incurrd to provide health facilities and

child development centes with all the necessary input in personnel as well as goods and

materials. Provcial/municipal incremtal r rent costs would be financed by the

Federal goverment counterpart conbution on a dedining basis. Specifically,

incremental recurrent purchases of food, drug and other materials -and incremental

reurrent salaries would be financed as follows: 100 percent, 70 percent and 30 percent

during the first, second and thurd year of implementation by the federal government, and the

balance, as well as all incremental costs beginning in year four, out of provincial and/or

municipal budgets. This would be specified in the subsidiary agreements between the MSAS

and the participatng provinces (para. 7.9 and para. 7.10).

6.9 The hiring of additional staff, when redployment of personnel is not feasible, and the

development of support services would be based on a gradual phase-in of project activies.

Upon completion of each provincial/municipil subproject, incrmental recunt costs (ased

on the fiscal analysis already made for the first 3 provinces) would be about 3-6 percent of

the ealsting allcons for social sector programs due to: (a) the small additional budgetary

allocations required by ambultry health care and eady childhood development programs;

(b) the lmtd financial weight of matnity departments in local, and especially general,

hospitals; and (c) the targetng of food supplemenion to the neediest. It is exected that

inal reallocations of provincial/municipal program budgets, including savings made in

existin school feeding programs, which may resut out of reforms to be undertakn with

project support, would finance a sizeable share of incremental recurrnt costs.

7. ]PROJECT ITL ' AION

A. Organikation, a ent and Coordination

7.1 OveraU Organiation. Project adminion would conist of two policymaking

bodies, the national and pvcial steering committees, and three maagement bodies: at the

national level, the Project Coordatng Unit (PCU); at the provincial and municipal levels

their respectve ministries of health, social welfare and eucation.

7.2 MSAS. The project woud be under the direct jurisdiction of the MSAS' Secrearlats

of Health (HS) and Technical Cooperation Projects (TPS), which would be the Bak's

official interlocutors (see Annex C, Chart 1). The Minister of Helth and Social Action

would make the final decisions in case of major disagms between the Secreaiats. The

Secretadats would: a) ensure that provincial paticipaion criter are applied consistendy; b)

exercise oveall supvision of the deir of the basic MCHN package of services; c)

oversee tecimical assstance and training programs; d) appoint, with Bank approval, the

PCU's directoro and d) orgnize and preside over Federal Steefing COmmittee meetings. In

additon, UNDP would provide assistance for moniting and transferring fumds to the PCU,

and possible for selecting and managing consultants who will cary out the national studies

(see pam 7.16).

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7.3 The Federal Steerig Committe. The Fedeal Steering Commitee (PSC) composedOf reatv of the Federal Minishty of Economy, Federal Secrta of Social Action,Peder Manal and Child Health Nadonal Dircto, miiste of beat or equivalent ofp otipt p ,vinc, professional associations (obsetticias, pediatcias and nurses) andNGOs would asist in policy development inlte-agency coordinaton, resouce use andperioic performance evaluation. The FSC would meet as reuested by the HS/TPS, but notless than once every six months to mrview the prqject's progress. The minutes of eachmeedng would be recorded and would become part of the next meeting's agenda FSCmembers would be paid a per diem, as wel as tsans on coss to th ses selected forthe meetin, by the project. Terms of reference for the FSC have been agreed with theGovernment and are in tbo project files.

7.4 The Poject Cordng Unit (PCU). The PCU has been establsed and fullystaffed to guide and coordino project iplemeon, pde teh a to theprovincial and municipal subproect UnitS, and monitor and suevs the implementton ofactvides under provincia and municipal subprojects. In addition, the PCU would desigand arove technical assstane proposals for institional strenenng as well as stdies.The oraizton and functions of the Project Prearin Unit in the MSAS were amendedby Pred a Decree No. 443193 of March 16, 1993 establishing the PCU to coordinate theimplementation of the proposed poect. The Bank has received a copy of the PreidentialDecree ceaig the PCU. During negotiatios assurances were obtained thalt the PCUwould apply the alrea agreed provincial pardcipadon criteria during proJectImplemntation (pare. 9.2b).

7.S The PCU's functions would include:

- carying out poricy and other HS sad TPS instructions- serving as a link among the differen MSAS units dealing with the proect, and amongte fera and prvnil maaeet levels- day-to-day proect administration, including speising the enforcement of

fedealprovincial, provincial/mumipalpticipati ageements- preparig disbursement requests, and managin the transfer of funds from the Ministry

of Economy and the Bank to the Federal Ptoject Account, as wel as to ProvincialAccut

- dismntig best prcie among pardciptng and nonparticipating provinces- reviewing and discussing with provincidal and municpa health and other relevant

mists investment props, commenag course of acdon to the FHS, andprovwiing technical assiance to provinces and muni for preaing andimplementing investment proposals, and in all other matters elatd to policy nd

- coordnat manpower development, incluNg training programs- mitoring and evahating project performance- based on the above, advising the ES and the TPS to terminate provincal areemt,

and to sig new aeements

7.6 The PCt's director (the Project Coordinar) and s dwuty, and the four PCUdeuty manager, who have been appointed by the MSAS with the approva of the Bankiwould be the opeatioal link between MSAS units, the Badk and povincia minstries Of

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social action or health. During negotiations, the Government furnished the Bank a copy

of Mniterial Resolution No. 170 of 4 June 13 nmIng the PCU Director (para. 9.1a).

The PCU Director would approve provincial investment proposal before sending them to the

Ba& for review. The PCU Direcor would approve cosltant contcs, and appoint,

tansfer, and remove PCU staff. HetShe would approve and send to the Bank disbursement

requests, easure that project guidelines, and norms for procum reporng, accounting

and auditing are folowed, and that invesments are made for the approved puposes, and

prepae biannual and annual implemention plam, consolidated bianual progress repots,

and anmul and mid-term evaluation reports for review and approval by the HSSTPS and the

Bank.

7.7 PCU staff are organized in four managment units (see Amex C, Chart 2):

programming, opeadons, information systems, and fmance and admiaLsaion. A lawyer is

resosible for assisting prvincial governments with leg aspects of organion,

management and finacing. Technical staff have been appointd for health, nutition, child

development, management information systems (including monitoring and ealuation),

logistics and institond stgthening activities based on job descriptions and terms of

reference, chronograms and rem levels agreed with the Bank Cm project files).

Assuances were obtaned during negotiations that the Government would maintain the

PCU with staffing satisfactory to the Bank for the duration of the project (para. 9.2c).

The PCU terms of rfce and the detailed opeional diives related to the PCU

repos ilities for proect impleme are contaned in a Project Operatons ManuaL

h fnal drft of the Manual was submitted to the Bank during apprais. During

negotiations, the Government furished the Bank a letter dated 4 June 1993 stating that

the MSAS has offcaly adopted the Project Operations Manual (pan. 9.1b).

7.8 The implementon of the provincalmuIcial subprojects would be monitored

closey by the PCU. During negoiions, assurances were obtained that the Gover_nmt

would funish the Bank (i) biannual reports of the physical and financial status of the

subprojects, and (1f) ot later than October 1 of each year an annual progrss report

and proposed investment plan for the foDowing calendar year (pan. 9.2d). Agreements

were abo reached that by the Project Mid-Term Review the Governent would furnih

the Bank an assessment report on the status of fte service indicators for the subprojects

Implemented (pam. 9.2d).

7.9 Provincial and Municipal Manement Angements. Provinces would participate

in the project on the basis of agreed crtia (see Annex D). Crteria include:

- lage absolute number of poor, who would also represent at least 30 percent of fte total

population in the selected m es- fiscal and ad ive capabilites to carry out the project as evidenced by fulfillment

cntywide critera applied to the Bank-assisted Prvincial Development Project

- political commitnent to basic health care and nutition, and child development as

evidenced by eistig and plamed resource allocadons, ongoing and planned reforms

- agreement to reform and improve the targeting and cost-effecdveness of provincial

school feeng prams based, at least partly, on project-financed analysis; and to

tca er the reslig savigs to basic bealth care programs

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- agreement with the proposed prject's basic heah and nutrition and early childooddevelopment service packages; legal and adminisve angems for geogmpicand popuation argeing, organizaion and managemen, staff taining, monitoringand evaluation; establishment of separte project accounts, accounting and auditprocedurs

- assignment of the required resources to the poject, including advance annual fundingallocations and adequate cash releases, particulaly for covern incremental recurrentexpenditures, as well as agreement to maximize staff redeployment to reduceincremental operating costs

- prepation with provincial funds of the provincial investment requests bad on theagreed guidelines

- signing by the provincial governor of the poincal agreement with the Mini ofHealth.

7.10 The provincial participation citeria include minimum and maximum investment limitsas follows: (a) as a minimum, one entire municipality would paricipat in the project; (b)the minium size of the target populadon (for Buenos Aires, the fifth and sixtf stat ofcensus raiuses of the Permanent Household Survey, and for other cides the population withunmet basic needs, would be 10,000); (c) the maximum investment per province wil bebased on the proportion of the poor population living in the province relative to the totalnumber of poor in the six selected provinces of the project; and (d) the maximum investmentper munipalty will on average not exceed 10 percent of total project investments or US$16million over a three-year investment penod. The Govemment funished the Bank duingappraisal the final draft Subidiay Model Agreemet between the MSAS and the Pwvincesand between the Provinces and the Municiplies partiipaig in the project. During

gotions assurances wee obtained that the MSAS would sign Subsidiarywith partpating Provices covering obHations applicable to all subprojects whichsuch Provinces are involved with tem and conditions satlsfactory to the Bank (para.9.2e). The sining of the Subsidiary Agreemet would be a condition of firstdisbunement for each Province (para. 9.3a). In tUrn, each Province, when required,would sign a separate subproject agreement with participatig Mes beforedibursing for eah municipal subproject (pan. 9.3a). During notiations a nceswere obtained that violations of these agreements would be suffident case forsuspesion of dibu en in the partpatg pvinces, and that cipatigprovinces which do not perform adequately would be replaced either by the remainingprovinces under the project or by other provinces which meet the paticipaton criteriaas agreed by the MSAS and the Bank (see para. 9.20.

7.11 Bach provincial miis of health (PMH) or his/her equivnt wold be responlefor evwing, coolidag and tasmitting to the PCU directr the provcial andmuncipal investment prposals. The first provincial investment proposal made for themunicipalit of Floricio Varela in the Buenos Airs Province was reviewed and apveby the Bank during appraisal, and the investment proposals for the Tcuman and Santa FcProvinces were receny completed. Th PMH or bis/her eqivalnt would also supervisesubproject implementation based on the general guidelines provided by the federal/provincialand provincial/municipal agreements, prvincial laws and regulations and project manuals.

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7.12 The PMH or his/her equivalent would be responsible for fund tunfes to povidd

and municipal publc service providers, enforemet of the provinal and municipalp n agreements, overa supervision, and the provis of support services (taining,

logistcs, and maintenae). The PMH may establish steerng commi;tt with similar

funcdtons and representon to those of the FSC.

7.13 The PlM or hislher equivalent would delegate the maxdmum amount ofiplemenon rponiilities to Provincial Executing Units (PE and when applicablMunicipal Executing Units (U) in line with Inplementation capcity. Tbeseresponsibilities would include pteparing ivestmen proposals, as well as managing the

purchase of goods and seices needed for sub-poject implementi, resource alocation to

field units, and field monioring and evauation. The project's orgnization stuctu and

management systems at the provincial and municipal levels would be based on existg

programs and institutional arngements for MCH1N and child development actvities.

Existing local personnel would be assiged to staff the PEUs and the MEUs; PCTJsconsltants and locally-bired consutants would provide technial astance and support the

wotk of local personnel when deemed necessary. The project's insdtutional component

would be managed by the PEMRs and municipal units depeding on their scope and size with

PCU technical assistance as required.

7.14 Operatios would be caried out both at the provincia and municia levels based on

the agreed opeaional mamuls ( project files), which provide norms and procedures to be

followed in the foUowing areas: procrement and distibon of goods and services, staff

management and taining, maintce, supervision, NGO and commuty participaton and

coordination, fining, auditing, and monitoring-evaluation. During appraisal, the

Government fuished for Bak review the final dr of the Operating Manuls. During

negotiatins, the Govenment furnished the Bank a letter dated 4 june 1993 stating that

the MSAS has adopted the Project Operatg Manuals (para 9.1b). The municpal unts

would prepare quartedy progress reports which would be discussed with and consolidated by

prviial ministries before being transnitted to the PCU dir and through him/her to the

PHS and the Bank.

7.15 Subproject Preparation Procedures. Subproject processing at the pvincial and

municipal levels would consist of tbree major actvitis:

(a) Preparation. Partic g provinces and mun s would prepare with the

suport of the PCU subproject proposals including a technical, social and economicjustfication for acdvities to be financed, in the ontet of the overl investmentprogrms m the paticiatng provices and mities; an assessment ofindividual compoent; the preliminary design of civil wors, and spVecfcaio of

equipment, pesonl, drugs and other medical sWpbes, chnical asta, and

stues to be financed; details o inshtuonal a gmets for execution of the

component, supervision of execution, and operatons and m nane; and financial

arrangements for funig increm recurrent expendimues, begiing in the second

year of subproject implemeion.

(b) Approval. Upon completion of subproject preparation the PCU would ass the

subproject proposal. Appraisl would include an evauation of the abilit of the

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participating provinces and m to meet incremenl recurrent eWenses. Theappraised proposal would be se by the PCU to the Bank for final approval. Durignegotiations assurances were obtaned that subproject proposals would beprted for Bank review and approvaI once they have been cleared by the PCUaccording to prolect gideies (parn. 9.2g). Once a subproject is approved, abudget, procurment, and disbusement cycle specified in Anex E would befollowed.

B. Procurmett

7.16 Prcurement for civil works, equipment, and materials would be done in accordancewith Bank guidelines (May 1992), using standard Bank bidding documents for In atonalCompeWtive Bidding (ICB) and standard docmen for Local Competitive Bidding (LCB).Procurement arangements are mmarized below in Table 7.1. The hiring of consultants forundetaldng studies and poviding technical assistance would follow Bank guidelines (August1981). For complex, time-based assigmnens, consulting firms would be employed using thesandard form of contra for consulting services isued by the Bank. During negotiations,

rances were obtained that the Governent has made suitable arrangemeacceptable to the Bank for handlig p-uenwt (ra. 9.2h). Since UNDP hassucceslly provided administrative support to the Bank-financed SSMTAL project, theMSAS and the Bank agreed to condder UNDP/Argentia, among other alteratives, tomonitor and trandsfer funds to the PCU, and to manage the underting of the national studies(pm. 7.2).

7.17 teonal bidding (ICB) is expected for the Socal Communication Campaignsestmated at US$4.0 million which would be procured through a two-step ICB procedure (thefirst step would involve p of bidders and evahlaton of technical proposals, andthe second, a call for prices on the bais of adjusted satons). The bulk of civil worscomprie rehabilitation and refudbishing of t ciLties. Civil works contracts valuedabove US$3.0 million would be awarded tough ICB. Coacs between US$50,000 andUS$3.0 million totalling about US$30.7 millo would be awarded thrwgh LCB inaccordance with procedures acceptable to the Bank. To the extent possible, contacts forworkS wud be combined in pakages of US$50,000 or more. For civil works contactsbelow US$50,000 local shopping requiing at least three quotations would apply up to anaggrgat amount of US$1.3 million.

7.18 Equipment for hospitls, healh centers, child development centers, informationsystems, and vehicles are expetd to reach a maximum of US$1.0 million approximately foreach individual subproject, over a three year period. During appraisal, a standard list ofmedical equipment and vehicles to be financed under the project was reviewed and apprved.All the subprojects would use the following pcedues for p ent of goods: ICBprocedre would apply for contacts higher than US$300,000; LCB procedures acceptable tothe Bank would apply for contcts between US$50,000 and US$300,000 up to an aggrgateamount of US$9.8 million; and local shopping procedures rceiving no less than threequowt would apply for purhases below US$50,000 up to an aggregate amount ofUS$1.2 million.

"44'

7.19 Consants carying out studies and technical would be hired following

Bank guieln. Contmc for smal consulng

US$100,000 or less, wold be formaHzed on the basis of standard ms of refaee and

employment contons accepable to the BaiW

7.20 During apisal the ist of gei dngs and the special con of the nutonal

packges and composiion of the forfied milk, to be financed under the proect, was

reviewed and approved. The following categories would be procured under local ptocedutes

because they wil be totaly financed by the fedal governme and/or the

provinces/muncalities: (a) dreg; and (b) milk and food upplemen.

7.21 Prior rview by the Bank would be requred for: all pUement do for

ICB concts; the first LCB contct of each suproject on each year; any civil work

contrct over US$300,000; and any contrc for goods higher than US$200,000. Pior

rview would also a]pply to procur of sertices o be prvided tbrough single source

contcts; c ng as valued at above US$100,000; and for the employment of

indvidals. Prior rview by the Bank for conwslting contacts vued at US$100,000 or les

would cover the tems of reference and the contc if a model is developed. All otber

conrac would be reviewed on an ex-post basis in the fild during Bank supevision

missions. Beause of the natue of the prject, it would be dificul to esmate the precise

number of conracts that would fall above t prior review threholds. Baswd on the data

available for the Flono Varela subproject, roughly 50 percentof the total number of

conrcts would undergo prior rview by the Badk.

-45-

TABLE 7.1: PROCURBMNT METHODS BY CATEGORYa (US*'OOO)

| CATEGORY ice ccaoTR NaF TOAL

Florenolo Varele bsuproJoot

CIvlt works 1,066 533t 1,599

Goods: Drnps 9f9 959- ~~~~~~~~~~~~~~(O) _(0)

Fe 1,188

Uqulpuent & Vehfctls 554 238i792_______________________________________ .___________ (446) (19 1) (637)

Training 450 450_________________________________ ._________ (450) (4 50)

1,768 1,7_ 8_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _(0 ) (0 )r Tochnfet lAssfstance 423 423

____ ~~~~(423) -43

Subtotal Floronc¢o Varela Subproj.ct 1,421 1,644 3,916 7,180(1,512) (1,597) (0) (3,109)

StudieS, T.A., Natinal Nutrtion 11,8W 11,863Survey, & __mp _t Evoluoticn (11,863) (11.863)

SocIal Commfneation CapIgn 4,000 4,000(4.000) (4,000)

_ tSV 15,202 15,202(15,202) (15,202)

SUITOTAL 4,000 1,621 28,709 3,916 38,246(4.000) (1,512) (28663 (34 7)

Future Provincfal ad Nmafcpat

Civtl Worsu 12,000 29,607 1,00ow 42,607_____________________________ X(12.000) (29.607) (1.000) (42.607)

Goods. Drugs 14,948 14,948I__________________________________ ___________ I_________ _ (0 ) (0 )

food 8,337 8,337

fpuip.mnt 6 Vehicles 4,000 9,3ii 1,000%/ 14,331(4,000) (9.331) (1,000) (14.331)

Trafning 3,642 3,642(3,642) (3 642)

Ialaw te 32,664 32,644_ _ _ _ _ ~~~~~~~~~~~~~~~~~~~~~~(0) 0

TechnfeIl Asstance 1,245 1,24S(1.245) (1.245)

Subtotal Future Provirnftl and 16,000 38,938 6,887 55,929 117,754munfefpal SueproJ cts1 t6,000) (8938) (6,8m (0) (61.825)

TechtI AssIsnce for 4,000 4,000InstItutfatl DloPtmnt 4,000) _ _ (4,000)

TOrAL 20,000 40,559 39,596 59,845 160,000___________________________________ (20,000) (40,4S0) (39,550) (0) (100.00)

# Totats fnltude tae nd eontinWne es. Ambwnt in paretsis Show Otloatton oft lon proeds.of rect contracting.Locat shappfng.Includes tae.includs staff salries, office quipmwnt, mtertsls, csultancfes, nd operatIonal pmnses.

-46-

C.D and Accounts

7.22 The proceeds of the prposed loan are aeected to be disbursed in accordance withthe schedule shown In Annex B, over a period of six years. The allocation of loan amountsand the dsbu perwe ar summaxred in Table 7.2.

7.23 La wihdmwal applcations would be fully documented for contct valued atUS$100,000 or more for consulants finns, and at US$200,000 or more for goods andUS$300,000 or mote for civil wors. Clams for smaller endes would be supponedby sements of , for which the suwotg domeaon would be retaned bythe PCU for perodic Inspecton by Bank stff and ex al auditors. Closing date will beDecember 31, 1999.

Table 7.2: ALLDCATION AND DISBURSEMENT OF I3RD LOAN

Amount of the Loan Peion ofAlocaed essed to be FnancedIn US Dollar gqiv._

Subprojects- Civil Wods 35,000,000 100%- Goods (ept dmgs and food) 11,800,000 100%- Conaant Services and Tining 4,600,000 100%

Consuktant Swrvica- social Cu Campai, 12,000,000 100%

NutritionalSurvey, Impact Bvaluation,Audis, and Stdi

- PCU 12,600,000 100%- InsttutonaDlvde pmen 4,000,000 100%

Unallocated 20,000,000

TOTAL 100,000,000

-47-

7.24 Specal Accout. To filitat timely project Implemenion, the FederalGovermet would establish, main, and operate, under terms and conditions satisfactoryto the Bank, a special account in US dollars at the Banco de La Nadon. To cover stat-upcosts for each povincdal spject as well as to fiance the prepration of additionalpovincidal subprojec, the Bank would make an initial deposit of up to US$8.0 millon to thesil account upon request. Project expenditures would be monitored by the PCU. ThePCU would request of the Speil Account on the basis of the standaddisbusemet procedues. Withdrawals frm the special account would be supported bysdufiently detd do natin or SOB in accordnce with Bank disbursementprocexu_s. Iln addition, subproject accounts with counterpart funds would be established ineach of the par provices and muices once a subproject has been approved.Me PEUsJMEUs would request from the PCU quarterly advances of federal and localcounrt fiuds to be deosied in provincial/municipal accounts to carry out promentof goods and services when these are to be done at the provincial level based on pastperformance and agreed work progams.

D. Accounting and Audting

7.25 Implementing agencies would maintain sepate project accounts that would beexernally audited anlly the Auditorfa General de 1a Nad6n (Goveranment AuditBureau; Publc Sector Finandal Admintation Law No. 24156, promulgated in October1992) or a smilar indqndent agency designated by the Government acceptable to the Bank.The audits would include the spea account and the statements of expenditures, and wouldcover compliance with the Bank's pu t procedures. During negotations, theGovernment furnishd the Bank the final draft detaled audiing procedur for both thePCU and the provincal and muniipal accounts (pars. 9.1c). Asurances were obtainedduring negotiations that the project loan account, SOEs, and Specll Account would beaudited in a manner satsfactory to the Bank, and an audit report would be presented tothe Bank no later thn six months after the end of each calendar year (pa. 9.20.

E. Status of Project Preparation

7.26 The health, nu m n,and child devsepme srvice packages have been agreed, anduni costs esimates have been made. Model nationaUprovincial and provincial/municipalagreements have been finaized. Provincidal parpaion cteria have been also agreed.Opeaonal manulds have been approved by the Bank contiing the organiatonmanagement, procement, acouxting, auditing, tbaing, monitorng, and evaluaionprocedus. The Florencio Varela subproject proposal was evaluated and approved by theBank at appraisal, and the Tucmnan and Rosario (Santa Fe) subprojects were recentlycompeted and presented to the PCU for review. The PCU was establshed by PesidenalDecree, and is fully saffed and operadonal (see para. 7.4). Job profiles and terms ofrefrene for all its members were agreed (see Project's General File). A Project

-48-

Coordinao bas been appoied (see paa. 7.4), as well as ae uni s.Govemmem prqject coneiput financg amountg to US$10 million has been allocated asa pecific ne item in MSAS's 1993 matemra and child budget (Budget Account No..Turisdiecl8 MSAS, Progrm 18). The first subsidialy agree_me, with the Provinceof Buenos Aires, has been signed.

F. Monitoring and Supervislon

7.27 The PCU would be responsible for overall project monioing and peiodic evaluadon.Monioding and evaluation would include two sets of indicatos: (a) progess indicaors thatwould rflect the smooth and timely mplemention of project activiies; and (b) outcomeindicars rated to project objectives. Durng negotitons, the Governmet furnishedthe Bank with a basi lit of these Indicators (see Annex F) which would be used as amnimum by paI g proviaes as speced In the subsidiary agreements (paa.9.1d). Additol work would be done by the PCU to develop reference benchmark daft foreach of the indicators.

7.28 Ealy in October of every year the PCU would prpar and send to the Bank for itsreview the last 12 months progress report and a proposed action plan for the foBowing year.After Bank pproval, the acton plan would become opetonal. The plan would be updatedevery six months based on progress reports that would be discussed with the Bank duringspervision missins. Progres repoRts would analyze actu and planned perfomance imeaching proces and outme tuargets; and propose changes in objectives and implementaion,as required. Governmnt/WBak agrement on the prvio progress leport's concludons andreomm lendations would be equired for apprval of the subequent acton plan and futuedisbursements.

7.29 Te project would reire subsantial Bank operion. About 30-35 staff weekswould be required per year in the first two years of implnaton,dii as projectdevelopment allows (see Annex G). Ihe supevision level is amply jusified. First, theproject would be the first Bank investment operaton in the scial secto in Agenina, whichraises the level of uncertainty. Second, much of the work would emerge during

and cannot be planned ahead: 6 provincs and a minimum of 16musklpaEtis would particpate, each with its own adminiative and lepl framework,service pfie, and efic argets. TIrd, a number of experiments in impoving eficiencyand efiveness of provicil and municipal health care systems would be carried out andrqu indiidl follow-up. Fially, the child developmen coponen Maddlng tfhe heathcare and the educainn areas, andinorporatng imaginaive new psycho-cial developmentsystems, wouxd re carenfl monitoring.

G. Mid-Term Review

7.30 The proposd project repesents an innovative approach to the delivery of MCHN andearly childhood development services. Implementation would prvide important lessons,which are ewxcted to lead to changes in project design and implemen ms.To facilita these prcesses the PCU and the Bank would joindy carry out bianual reviews,as well as a mid-term review at the end of the third year from effectiveness or when one halfof loan funds are disbursed, whichever happens earlier. During tiassuranceswere obtained from the Govemment that the annual and mid-ter reviews would becarried out (pa. 9.gj).

H. Environmental Impact

7.31 The project would not have any sigficant advese impact on the envn, andhas been clasiied as Type C. Standard sfety procedur would be followed in therehabilition of the health s c, and in the installaion and operation of equpmentsupplied under the project. Prcedures for safe anling of hazardous wastes and matealswould be included in th aining program for health personnel. In additou, health andnutritiom education campaigns would inform beneficiaries in project areas aboutenvionmental ris and measues to reduce the spread of communcable diseases.

L Impact on Women

7.32 Poor women would receive pre-natal, child delivery, and post-natal cate, as well ashealth and nutrition educadon and information. Pre-natal cae would detect poten birthcompications, while delivery services in local hospitals would be imrwved to handle nomalbirths and birs with compons. Post-natal care would include information on biffhspacig, which has a great potential for enhancig the health status of mothers. Thenuitlonal status of prgnant amd lachtting mothers would be improved thogh nuitionsurveiance and food supltin. Child care cters would free women to workoutside their homes.

8. EXE:CTED BENEflTS AND RIMS

A. BeneIt

8.1 The princpal benefit of the proposed project would be reducing death and ilnessamong women in the reproductive age span, pregnant and lactang women, and childrThe project woud also promote full physical, mental, and social deveoment of childrenunder 6 years of age. Project int would improve infant and child survival andmatenal health, reduce the pevalence and severity of the most common dies, andpromote the care of young children, emphasizing their physical, emodonal intellecu, andsocial develment, which is likely to improve learning acievement in primay educaon.

.50-

The project would also initiate a process of managrial and operational improvements inprovicial and munpal socidal programs for the dehvery of MCHN and early childhooddevelopment services. Provinces and munices would receive practical taining inplannig and implementation.

B. Risk

8.2 In general, provincial and municipal healt administaon in Argentina is weak, andthis weakness limits the potential for improving and expandig services. However, theproject has a simple design, and is adapted to prevailing coons. Polidcal commitment isstrong both at the national and the local level, and liMely to be sustained, not only becausepresent administrations would be in power undl the end of 1995, but also because MCHN isa national issue transcendg political pardes. The project is targeted on 6 provinces and ahandfil of munici es that meet stringent pa on ceria. Beneficiary groups arewell defined and live near targeted services. Only two types of interventions arecon plated (MCHN and early childhood development). Implementaion would proceedalong d li lines, diminishing the impact of possible botenecks on the project as awhole; and would be based on existng administative stuctr and norms. Subsantialtechnical assistance would be provided at the fedeal and provincial levels. UNDP wouldsuppoxt ainistraion and UNICEF would assist with taining, monitoring and communityParticipation.

9. AGREEMETS REACHIED

9.1 During negotiations the Govenment furished the Banic (a) a copy of MinisrlResolution No. 170 of 4 June 1993 naming the PCU Director (pam. 7.6); (b) a leter statingthat the MSAS has officially adopted the Project Oprating Manuals (pam. 7.7 and pan.7.14); (c) the final draft audit procedures for federal, provincial, and municipal accounts(pam. 7.25); and (d) a basic list of indicators to monitor provincial and municipal subprqects(pam. 7.27).

9.2 Assurances were obtained during negotiatloasthat:

(a) the Government would not later than October 1 of each year during the execution ofthe Project, submit to the Bank for approval the investment plan for project acdvides,inchuding technical assistance allocations, during the next succeeding year (paa. 6.7);

(b) the PCU would apply the agreed provmcia particpion critia during projectimplementation (para. 7.4);

(c) the Government would maintain the PCU with saff satisfictoy to the Bank for thedumation of the project (pam. 7.7);

-51-

(d) the PCU would furnish the Bank: i) biannd repoit of the physical and fiancialstatus of the suLprojects, and (h) on October 1 of each yea an annual pwgress reportand prposed investmen plan for the follig caendar year (pai 7.8). A,gemnwoud also be reach that by the Ptject Mid-Tem Review, the Govemt wouldfiuish the Bank an assesment report on the status of the sevice ixdcator for thesubprojects implemented (pan. 7.8);

(e) te MSAS would sign SubsidiaW Agrements with I Provinces coveingobligati applicable to all subprojcts in which such Provinces are involved withterms and conditions satisfactory to the Bank (pan. 7.10);

(f) that violais of MSAS/Rovinces and o eements would besuffient case for suspension of dibur t in the Pa provinces, andthat p provinces which do not perform adequately would be replaed eitierby the remaining provinces under the project or by other pwvinces which meet theparticptin criteia as agreed by the MSAS and the Bank (pam. 7.10);

(g) provica subproject proposals would be presnted for Bank review, once they havebeen cleared by the PCU accoig to project gudeln (pam 7.1Sb);

(h) the Govemment has made suitable acoeptable to the Bank for handlingproemen (pam 7.16);

(i tie project loan accout, SOEs, and Specil Account would be audted in a mannersa cy to the Bank, and an audit report would be prented to the Bank no latrthn six months after the end of each calndar year (pam 7.25); and

(j) the anna and mid-tem rvews would be ried out (pam 7.30).

9.3 Conditios of Disburseent:

(a) the frs dit o each i g pr e/muni iy in the project wouldbe subject to the signing of an agreement betweea the MSAS and the Prvice, and,if required, between the Province and the M, with term and conditonssatsfacoy tD the Bank (pam. 7.10).

-52 -

AmuuA

PROJEC ACION PLAN STUDZES

Study lmetable Stusllmark

A.1 Natoal Nutrtion Surwy

lTams Of Rue : Nov. 1993 Outline and ObjecdeAgmed

Contact: SFeb. 1994Start March 1994Completion: March 1997

A.2 Impact Evaluaion Studies

Tam Of Reerece: Nov. 1993 Outline and ObtectivesAged

Feb. 1994sart: Mach 1994Compleon: March 1997 and 1999

A.3 Evakbton of NaDional FoodnSupV -*[ Peogam

Tams of Rerence: Dec. 1993 Oudine and ObjectvesAgmed

Contract: hMarh 1994Start: June 1994Completion: June 1995

Annex B

- s3 -

ARGENTDNA- MCEN PROJECT-ghnkted E_a ed Costs

(US '00)

- _ Local Posip Tota S Poaip s d

. ~~~~~~~~~~~~Exoag Ba..cost

plormnolo VSgua 5,117 2U9 5,336 4 4

Futu 0Sub*m 111,704 6,050 117,754 5 78

Subtoa 116,S8 6,6 123,091 5 82

N jiovl Nutdtioo 9mvew 5,630 0 5,00 0 4

Proje Ic svauto 1,930 0 1,30 0 1

Sbdiea and Azdu 1,487 0 1,487 0 1

_0__o_ ______d___ _P _ __ 4,000 0 4,000 0 3

Teh Asdhtne wr 1et Develop. 4,000 0 4,000 0 3

I~~~~ -CU -

Poml 8,82I 0 8,825 0 6

Teolcal A _iataae 6SO 0 650 0 0

Tavel and Pet &n 514 0 514 0 0

Compuew Equipmn and Sotui 0 73 73 100 0S~ - ---

O0ce Mae dat.sod Sevc 359 0 359 0 0

Sublotal 10,347 73 10,420 1 7

TOTAL BASE COST 144,215 6342 150,557 4 100

c d C _ Soodusmi" 838 13 850 1

Price Co _dngumu 84S83 9 8,592 6

TOTAL PROJECT COST 1S3,635 6,36S 160,000

al PMU staff would perom varlous tus: () mOf ovemf l roectimpleenio; Z() prOviSion of tchnicl asthae in t p_pbation andimplementatio of prvhinc nd municia subprojes; (ii) eview andevalaon of provia and muica subwject proposas; and(IV) nt of naoal iand ampaigns.

FLOgUHOIOARELAlUXM%IO.T MMRt: IUSM YM*R nod4 WEARM: 16I WAR t 169 W.ARS t OS WAR* 396 TOAL

COOINSW LOG WM4 TMT LOG RMe TOT LOO FRAN TOT LOG FROI TO LOGM F WI O LOrB MME TOT LOG MM TOT

pwmmminUaw.a to1 0 141 soS a an US4 0 so 66 5 16 a a 0 0 a 0 OR? a 95adMa-lT 47 a 47110 0 10 114 a M1 as 0 as a a a 0 a a US a U

b*uambiSu 16 a U 414 0 40 0 II 0 0 0 0 a a a 0 0 0 76 a 70Uq4uimw us 14 go 0 0 a 0 0 a a B B 0 0 a a a 0 as 14 meOnig It4 ai la0 15 OR 60 m7 us Ot is0 as la$ a o o o a a u "a t

Vdd,- as so 74 0 a 0 0 0 0 0 0 a 0 0 0 0 0 30 31 14 m

sdd-Tm 0 a a 4 0 4 III 0 to 7 a 7 0 a 0 0 a a go 0 go

Po mainmwdwwuis-0Ui 0 a0 BIt 0 0I uS a 1as lt a ast a 0 0 a 0 0 V6 0 ITWASIMAIANS a * a go on mite o a 11 a a a 0 a 0 0 B IG 0 1its

TdiIMb I 0 it 60 0 U t7 0 7I 0 0 0 a a 0 0 0 0 to 0 to

VaJ~~~~~~~~~s ~~~11 tO I 0l B 01 01 0 03 0 3 '0 0 0 0 0 II o 10IUTowtiLCFR.diw UWI gg o 61 13 a go6 A 4 Al to toIl a a 0 0 0 1*4 tO Ids

FosUsd1 It 0a 21 47 a 7 6 0 ISa a U 0 0 a0 a 0 0 It6 0 l 9CuaF 0EVAUWI B 0h10" 0 tOO 161 a 16 166 0 tUb B a I a 0 0 716 0o 1,6

Fowdfdt so a 0 41 a 01 as a 10 a9 0 so 0 a a a 0 10 t7a 0 3USOT RIeaI A 131 "aB a IGO 44 0 444 ids a too B 0, B7 . 0 1. 0 71.1mm a Ro Oa ea o a r a a

O~~s4vEqs~~~~imult ~~0 a3 11 a 0 0 a 0 0 0 0 0 0 0 0 0 a 0 0 Ua IsVNIS 6~~~~ I 1 a I I I I S 4 1 4 0 0 0 0 0 a to 4 Os

UBTOT&FI4v.FRW.IS.IowbODom 8 a8 Is a I 7 7 I 0 4 1 4 a a 0 0 0 0 aO in as

513R960 19t S UNt "a 0 1013 0 UfS a a a 0 B a a 0 5 401 S 450

UqAasu4 "a a 41 as 0 S0 0 0 05 0 0 0 0o a a 01 0 a 4a a 41ToglAMdPumn 0 42 B0 0 0 0 0 B 0 0 B 0 B 0 0 62 0 16

GUOTOM.LUMASSITNOMM ~ m a02 0 0 31 45 a So Oa II la S 01 4 0 406

TOTA.COS An6 US 1O2M .111 6 AS 4 ' 6 1 0 I *4 06 1.10

55 ~~~~~~Ann= B

FINANCING PLAN(USS '000)

|_._..__ PFinancing

Total Prject IMD Govevm_ Pvi

I _ __._ __,_ Costg/ . _ , plites I

PCU I15202 15I202 ._..._.. __.

Nadtonal ition Survy 7,562 7,562

project Iupact Evaluato 2,81S 2,81S

Stdies, Audits & Tec AssL 1,487 1,487

Social Communication 4,000 4,000Campaig

Tech. Assist fbr Ins. Deveop 4,000 4,000 ._

Floreadco Varel Subpro_ _ ____ _

staf Suarsno k/ 1,768 0 1,097 671

Dmpg 959 0 613 346

Food 1,188 0 711 477

i *rastructure 1,599 1,599 0 0

Equp t 697 542 90 65

Vehicle 95 95 0 0

Trainisg 450 450 0 0

Tedhial Asisdance 423 423 0 0

Futue Provinuialfuoipl4Sbproject . .

Staff Salauies k 32,644 0 23,554 9,090

Drugs 14,948 0 8,676 6,272

Food 8,337 0 5,258 3,079

In2frastructre 42,607 42,607 _

Eqipmnt 13,683 13,683 0 0

Vebicles 648 648

Traling 3,642 3,642

Tech_a Asistac 1,245 I_ _ _

Tota Projed Cost 160,0Q0 lO,C 40,000 20,00

IV TOMa may no 84d4a SOe touUSk/ lIcludes e and moetry inctives for staff ing and buses for cild dvlpmet ceters'

anP psq - .

- 56 - Anm B

ALLOCATION AND DISBUSENMNT OF IBD LOAN

Amnt of the Loan Ot iAloaedM ed to be Fucd

Subprojs%- Civil Works 35,000,000 10%- Goods (epqt drugs snd fod 11,800,000 100%- Cons t Services and Trag 4,600,000 100%

m Scid ComuCampain 12,000,000 100%

Nuional SurWS, Impact Evaluation,Audits, and Studies

- PCU 12,600,000 100%- ptionalDevot 4,000,000 100%

Un.ocated 20,000,000

TOTAL 100,000,000

9 ' t11

IA tt ... iitst Z

§ {}Xl1 }1Xœ ] ] 1]Xx S ] (}1t1I

* -58¢ CAn@C

zmm2UZP GM, OF IT3?? 3LNAIEOh azo

EZETIR Ors alnQ

SECRt ~~~~OOORALl£S2Z 8

FOR SID AJDTWK ATII~~~~MG

IzCaTRZAT&

NATZM=ACPRLD ACT

aMDPROJEC

-59 eAn C

C bKs-LSM

COORDINATORDUCTO

PROGUAIO(aNG OPURATIOULrpt&TO J

WiNAOnR MANAGaR 8YT8T32 ADMZNISTRATIV

SUCTUZALSPNCIALISTS,TECUNICAL AND ADNINISTRATIVU

SUPPORtT STAFF

PROVINCF1LOM! mULTJNTJ

-60 - Annex D

SUBPROJECT CYCLE AND PARTICIPATION CRITERIA

1. The wide variation of policy, insiuonal development, manaement systems andcapabilities, and financial resources, of provcial and municipal health care services stronglysuggest the use of fund mechanism for proect implemeion. A fimd mechanism wouldfacilitate a demand-driven development process where progress would be linked to thecommitment of providers and local aminions. It also simplifies project desig (fewercore elements) and facilitates provincial participation by limiting the number of basicrqiements

2. Additionally, the fund mechanism is cost effecdve. Moreover, it dmately wouldpemit implementing a basic core of natonal policies and sevices, while leaving the requiredflexibii to province and municipaliies to apply the naional standards and improve orexpand services on their own with their own policy decisions and capabilities. By promodnglocal ownership through a system of rewards (additional avable fundin and technicalassistance) based on perforance, the proect would enhance the commient of prvidersand services users, effiiency, and eventual impact.

Paicipating Agencies and Procedures

3. The govermenl agencies involved in the proposed project include the Ministry ofHelth and Social Action (MSAS) through two Secretaias: Health and Projects/TechniclCooperation. The Project Coordination Unit (PCU), lcated m the Secetnats, would beresponsible for project coordinton-including oversight of resource flows among executingagencies and beneficiaries- as well as providing the adminiatie ke between andamong federal agencies and provincial governments partcipating in the project.

4. The two coordinadng commitees under the project, the Fedeal Stering Committee(FSC), and the Provincial Steering Committees (PSCs), are concerned with the compatibilityof national policies with local activities under the project.

5. Subprojects would be formdated by Provincial Implementation Units (PEU) andMunicpal Implemenation Umts (MEU) usig: (a) the elgity critena agreed with theWorld Bank; (b) the methodology designed for subproject preparon under the project; and(c) the guidelines for subproject presentation and evaluation.

6. Subprojects proposed for financing under the project would have to fuli thefollowing rqirements:

Formtion: to be done between provders or groups of providers and localcoordinating agncies, presentng ideas and requirements based on above. These proposalsultmately would be submitted to the PEU which would consolidate the proposals.Subproject preparation activities would be financed using funds provided by the provincialhealdth entites, local commus, and non-governmental onions.

- 61 - Annex D

Prioritdzation: the PEU would rak and orgnize the subroject for submissionto the PCU based on project guidelines.

Evaluadon: the PCU would analyze each proposal either approving orsuggesding reformulaion and/or rejecing it for not being in conformity with pmcedur andcriteria estblshed under the proposed project. The Bank would receive all subproectpropols peliminarly approved by the PCU. The Bank would subsequently communiatin writiDng to the PCU whether it approves, sugges changes, or rejects the proposal.

Agreement of Conformity and Execution. An agreement would be signed bythe provicial Governor and the Federal Minister of Health and Social Action delineating theobligations and rights of the provinces and the MSAS in undertakng subprojects, assigningresponsities to the respectve parties, and specfying criteria for suaibility of thesubprojecL

Budgetary Framework

7. Approval of Subproject Budget. The budgetry approval process consists of thefolowing: (a) all subproject proposals would include a detailed cost breakdown per activityand per year; (b) together with subproject approval, the PCU would set a maximum amountto be financed for each subproject; (c) immediately after subroject approval, the PiU wouldestablish the budgetng process and prepare a report detailing how the activities expected tooccur during the frst year of the subproject would be implemented.

8. The subproject would be approved initially based on the subproject proposal,inculuing and amount for contingencies. In approving a subproject, the PEU would requestof the PCU an official tansfer of resources (see Manual for Program Planning andBudgeting In Project Fles). The procurement and conwactng systems, which should beused in all admive units with bidding and administrative capability, is described in theManual for Purchasing and Conhtacting (in Project Nloes).

9. Prequitr for Bidding. Bids may be sought following the guidelines described inthe Manual for Procurment and Contracts if the following conditons are met: (a) thesubproject has been approved by the PCU; (b) the bidding documents necessary for callingfor bids, satsctory to the PCU and the PEU include: general specfications; paricularspecificions, technical speifications, engineering designs and/or architectal plans (ifapproprie), procedures for budget earmarking cleared by the Ministy of Economy andProvinal Fance Miistry; support and execution arrangements compled.

10. Terms and Conditions. The officers authorized to contract for drafting the Termsand Conditions should provide for all arngements, preq0usites and/or guarantees to ensureproject effecdveness and efficient execution (see Manual for Purchasing and Contracting).

-62- D

Resource Allocation

11. Fund Estmation. Prior to the bidding, the PEU should inform the PCU of theestimated funds that would be needed for the execution of its subpwject (Manu forProgram Planing and Budgting). The PCU, usig the information provided by PIU,would prepare a funding program that aggregates all necessary estimates for all fundg bythe PIU and send it to the Administrative Authority of the MSAS for the purpose of enteiginto negotons with the aWropriate govemment body to deliver the neessry resources.Once the contc has been signed, PEU would send to PCU the detailed funding programfor processing.

12. The PEU, after taking into account any changes from the orgia proposal, wouldsend to the PCU a quartedy estmate of funds disbursed during the period. Theprogramming of funds should occur no more than 15 days after receipt by the PCU, andshould contin details about the following: legal agreement between the Govement and theBank for each subproject (assigned by PCU when the project is presented for approval);percentage of fancial advances by date; monthly expenditures; and updated balance.

13. Transfer of Resources. The PCU would anrange for the transfer of resources foreach subproject presented. It would als have the authoity to modify or suspend resourcetransfers if the execution of one or more subprojects does not conform to projectrquire:ments.

14. Statemens of E endi. After fulfilling the terms of the contract as agreed withthe Bank, the PEU would: (a) remit to the PCU within five days of the end of each monthinformation required for the 'Subpwject Statement of Expen (see -Manual forProgram Pannig and Budgeting"). Eas information would be analyzed by the PCUrelative to the subproject fincial plan that the PELU and the insitutions involved in thesubproject have pesented at the beginning of subproject implementation (see Manual citedabove). The PCU would study this information and request fiuther information if necessary,to be provided by the PELT and the pertinent intions.

15. Information and Auditing System. An information and awditing system would beput in place for subproject implemention and would be available for accesing by Bankstaff, the PCU, the Federal and Provincial Accounting Offices, as well as indepenentauditors designated by the PCU and/or PEU (see Manual for Auditig and ProjectRecordkeeping Documentation).

16. Official Correspondence. For the purposes of quicldy m ing informaabout subpwjeCt implementation, official communiques would be as follows: (a) allcorrespondence from PEU would be sent direcdy to the PCU Co=dinator in the form of aleter signed by the PEU Coordinator, (b) simiarly, the PCU Coordinator, or a desigewould use a letter format when reesting the requied project information fom the PEU; (c)all communications of the PCU Coordinator with the Secretary of Heah, the Secretary forProjects and Technical Cooperation, and with the FSC would be by official memoranum.

- 63 - Annexc 0

Distribution of Resources between Jurisdictions

17. The Federal Govenment would determine the maxdmum amount of resourcesavailable for each of the 6 selected province based on the prcentap of the tauget populatinliving in the province relive to the total of the 6 selected provinces. During the secondyear of the project, PCU would separate provinces by subproject pproved and determthat collectively these subprojects do not exceed a maxmum fndig level based onprovincial trget populaion criteria. PCU would then inform the FSC and each jurisdictionrelative to promoting any additional subprojects in compliance with establshed guideUnes.

18. Provincial requests would be received by the PCU up to 6 months before theestimaed closing date.

19. The MSAS, in agreement with the Bank, can redefine the preeMblished municipalfinancing ceflings based on the difference between the target populat coveted underapred subprojects and the needy populatib who raay not have been read by these

subprojects. This can be done by rg resources not alrdy allocated, afterensuring that there is an adequate ca to execute any additonal projects approved. TheFSC would routinely inform the provinces of any such allocations.

The Subproject Cyle

20. When the PCU becomes operational, the two Secraries would ivite the prvinc toident subprojects for fiancing under the prposed project. Rep ves from the PCUwould visit all provinces that have eVressed interest and submited a report xpling theimplementtion and financing capacity that exs to cany out their suprjects. This reportwould be prepared with respct to the project paiciaton crta, pecifng whether theyare able to undertake subproject formulation or require PCU's technical assistance for thispurpose. The provinces that have the capacity to ps a subproject would still be able toreceive spport from the PCU in its formulatio After the proposals are received, the PCUwould analyze them in terms of the established eligibility crteria. If not all criteria are met,the PCU would work with the prowvncial prese tives to resolve any problems.

21. After the subproject has met all tecal reqirment for aproal, the PCU wouldinitate the necessary adm ve actions for ftzdi. Pwvins would not be eligible tosubmit proposals if by the end of the third project year they still lack the capacity to preparea subproject as specified in the eligibilty criteria, based on the evalhidon of the PCU.

Evaluation of Provincal Capacity to Inplement a Subproject

22. The capacity of the provinces to implement subprojects would be based on exstcapacity in the following areas: (a) types of progams that exist simlDar to thos pposedunder the project; (b) capacity of local organizatns to plan and upvise eisting programsin project areas; (c) quality, number, and experience of staff in local insttudons in the aof planning and supervision; (d) experience within the last five years in execting programsaddressing the project requirements. For the latter, special atention will be given to:

-64- AnniD

(a) avality of budgety resources that thmse indtons have had in the as five years;(b) eisting procedu fr admisttio of esources relative to actualm _anagemnt ofhuman, material, and financial resources; (c) reaiohip with the Mistiy/Seretazy ofFiance and auditng and accounting bodies; and (d) dated infomation In the provincialproposals.

Crtra for Subproject Approval and cinadng

23. For obtaining subprect financing, the pvinces ould meet the following ciateria(a) subproject proposals should be related to the oveall ptojec in tems of objectives,actvites, resources available, and adm ve o on; and (b) the caacity andagreemes of the prvincial and m i govem svolved to enmre sa b.

Subproject Critrak

24. Project Size. Subproects should be at lst municipl in scale: hence, at a minimum,a network of health center that =faitate meetig the needs of the targe poulato in themunicipality. Furtherr, coverg should extend to no ls tn 10,000 people. If thereare s mui e involved, then contguous munkicipais can combine to meet theminimum coveag target. In both cases, the target popation mt be low-income goupstat ue pubc heath and rlated fiities.

25. Targeting. The operational defintion of the target populon ismunicialite where the poor repesent at least 30 percent of the populat

26. Org. subprojet sould involve onizatons that curTntly exi,including pvincal, municpal, and non-govmental en. The PU shoud remain inplace for the duti of the subproject, and is responsible for all laison with the PCU at thenational leveL This involve inersectorl and intrjursdictoal coodntin of the projectreaive to caiyig out its objectves and estblshing and confoming to project norms.

27. I a I.h pvinces should develop ubprojec as ntegrted basic packagesiclding activities in the area of health and nutrton, and hopefuly in eary clbhooddevLopmeaL

28. Moitoring. A moitoring sysem should be se up for wUpact actvities,hnluding a system of accounts and auditg that at a inimum inchludes the elements of theproject basic packas in a way to facilte the prcsing and flow of n.

. _PRONCIAL OR CONTROLLERACTIVITIES SUPPLIERS MUCPX P.C .U. TIBUNAL VACIONAL

EXFCUTItn Y PROVINCIAL DS. Xz~~UNT CUZENTAiS

APPROVE SUBPROJECT.

SEZND STAARD BImDOCS.

PREPARE INDIVIDtALBIDS

INVITE SUPPLIERS

SUPPLIERS REC. BID

DOCS.PR13SMGT OFFgR

AAYZE3 AND AWARD

VERIFY AMWADS

SIGN CONTRACTS a .

ISSUE RESOLUTION -

SEND FOR REVIEW

APPROVE RESOLUTION

BEGIN EXCUTION 6 -

REQUEST PAYMTFOR ORDER

REvIEW PAYMENTREQUEST .

PAY ORDER

PROGRESS REPORT 0_

-66 -AnnoC P

BASIC LUST OF PEREORMANCE NDICATORS

1. A basic list of performance dicora agreed at ngoan andwoU be used as a mnimumby p ua. p s as qeit.d in to

agmemmb Other indicato to mont pwvlncia and municpoj wd be chosen fiom the comp pMesive Hlt of pnoect

indighfcators detale In this annx dependin on the nturs of theneentionstobefinanced. eindiatinthebasdicHstwereseected on

the basis of te foowing citdua

1. lODship pbhyial resoucs and actvides inanced bytbe Bank

2; Abiity to smma die t ults of another sere of ;niatothat are sable for the monti and ealuto ofactvides at each vel ofi.

3. Ability to provide an overiew of the degme of Implmeaionand resul of the nadond program.

2. Ihe basic montrn indicatr are:

MON1IORING OF SERVICE PROVIERS

1. NO, hl t in do pn.mum QuatelyMal nber of health centers plhed

2. NO, _n fo ld in 98qmm QuaterdyTAal number of d ce for cilr planed

3. NO_ _ In_mm__ QuartedyTD nmbero nexes pki*_d

4. No. ld dm ent centersn AnnualTal number of child deelopme cedt paned

1. NF Ow ose &M hsdla mo,*= inbid aid whipm co ul 0 with theaommy nquhmnea% both pIy.icadioo nd pubp of sevice, wol beemiMudgd - amb

-61-

PROCESS MON1ORtG

EQuawnyS. NQ. pmgt womlen reitrd inte mm QUatly

No. of pgnant women in the aget 1poan

6. NQ C naa o Quarty

No. of prgnat wm regisered in pm

7. No. c rg. in am a gam S -aNo. chidrean in tat popu n. by ag p

8. No. recovered malnourised cbdn, by age go14tand bY degree of malnutrition Semi-anm

NO. m children In arget pplaton, byg gSoup and dege of mautrito

9. No. curg manouished chlden, by age goupnd bg dee o malfo Sem-

No. ml cldren In rp byag oup and dr ofm

10. No. Cd constations. bi ane m _ QuateyNo of chldren regtrad in prpm, by ag group

3. Ech one of these indicators would be detmined for each level of

implemenaion of the proyect munipal, provincal, national

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cww %boo *I hime I d=.tW 600 a*. uc sn" dmoe lioasosemo

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sb~~ummI WdI aI bye.s*e.I b d Owebria

-- ~ d * rtt.-a -- U.. dhu .mu U.d*,.U U.uIU

__ _ _~d tNX _-10

one*iO leto h.ibfami 06mo bAsby 86- y

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=bb 4mn"atof fl"- s bmeinIS*i 01sca ou* M* "161- odbSb al t wb o ya

dmV _oks - W ml -- _810

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- U__. U0 I_ _bblu MdUOleb#

W*Ar~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~i

-78-

Annex

SurlkVZION PLAN

liming StaffWeeks Staffng

CY1993 10 (Project Launchl(Second Half) Appraisal of Subpoject)

-Task Manag (4 week)-EN Speciai (2 wees)-Opewations Speciali (2 wee)-Other (2 weels)

CY1994 33 (Supeision/App.ail of Subprects)

-Task Manager (15 weelm)-EN Specalsts (6 week)-Opwaions Specialig (4 week)-other.MIS Specalist (4 week)Early Chiood DeveomentSpecaist (2 week)Adiistration(2 weeks)

CY1995 30 (SuperviAppaisal of Subpts)

-Task Maar (13 weeks)-EN Speiaists (6 weeks)-Opeaaions Spedalist (4 weeks)-OtherMrS Specalst (3 week)Eary Childood Devlopmetspecalt (2 week)AdminIstrat (2 week)

eo m Ct

XI (I U) g

_z6§Xt K%Wg tgg

Ig1XAA IXAAf IX lilt

- 80-

Annex H

DOCUIEENTS IN PROJECT'S WORKING FILE AND GENERAL FILE

A. Technical Annexes. The below listed documents were prepared by the World Bankpreparation team on the basis of reports presented by the PCU during pre-appmisal andappraisal missions. These documents are part of a Technical Anmexes Volume In theProjects' Working File.

Annex A. Vital StatisticsAnnex B. Overview of Provincial and Municipal Service IsuesAnnex Cl. Basic Health Services PackgeAnnex C2. Matemal and Child NutritionAnnex D. Early Childhood Development ComponentAnnex El. Training PlanAnnex E2. Information SystemsAnnex E3. Social CommunicatonAnnex E4. Reo ion of Schools Feeding ProgamsAnnex Fl. Terms of Reference for National Nutrition SurveyAnnex 12. Terms o& Reference for Impact Evaluadon StudiesAnnex F3 Terms -f Reference for Evaluation of National Food Supplemention Program

B. General Documents. The below listed documents were prepared by the ProjectPrepamtion Unit of the Argentine Ministry of Health and Social Action with the support ofUNICEF. These documents constitute the overall project proposal.

B1. Documents Related to Project Component (in the Project's Geneal Pile).

Documento Final del Proyecto.

Anexo 1. Estadisticas VitalesAnexo 2. Organizaci6n de los Sistemas de SaludAnexo 3. Actividades de NuticidnAnexo 4. Servicios de Atenci6n PrimariaAnexo 5. El Programa Materno Infantil y el Financiamento DisponbleAnexo 6. La Organizci6n de los Servicios de Atenci6n Primaria y

GerenciamientoAnexo 7. El Paquete Bdsico de SaludAnexo 8. Evaluacidn de la Infresae ctura ExistenteAnexo 9. Hospital Local de ReferenciaAnexo 10. Reformulacion de los Programas de Comedores EscolaresAnexo 11. Desarrollo Integral de los PreescolaresAnexo 12. Procedimiento de Compra de AlimentosAnexo 13. Capacitaci6nAnexo 14. Comunicaci6n SocialAnexo 15. Sustentabilidad del ProyectoAnexo 16. Organizaci6n y Gesti6n del progmma

- 81 -Ane

Ane=o 17. Sistema de Monitoreo y Rvaluaci6nAnexo 18. Investigaciones OperacionalesAnexo 19. Definici6n y CAIculo del Tamao de la Poblacin Otbedvo

Apence 1. Caxacteristicas de la PobrezaApendice 2. Salud EscolarApendice 3. Antecedentes Sobre Evaluacd del d NuticionalApendice 4. La Compa y Distxibuci6n de AlimentoApendice 5. Especificaciones Sobre Calidad de lcs AlUieotsApendice 6. Especiflcaciones Sobre Requeimieto de Plego pan la

Compra de AlimentosApendice 7. Descripci6n del Trabajo de CampoApendice 8. Instrumentos de Recolecci6 do Idb=ai6nApendice 9. Antecedentes a y Ped

de Cargos doe las Unidades EjecutomApendice 10. Listdos de Menues y Opciones de DosaymoApendice 11. Composicid6n Nutricional de las Listas de ComidasApendice 12. la Mortafldad Infantil y la Pobreza.Apendice 13. Metodologfa par la Esdmacidn de Coss

B. PROJECT INpL?EMNTATION MANUALS (in the Project's. Geo=l PMe)

1. Organizaci6n pam la Ejecuci6n del Proyecto2. Manual de Normas Contables del Pzoyecto3. Auditoria del Proyecto4. Compras y Contraciones del Proyecto5. Manual dePpresupuesto y Anexo6. Mana do Opemciones7. Subsistema de Efectores8. Evaluaci6n de las Finanzas Pblicas de Ias Iuridiccioies P as

IRD 24782

)870+ BOLIVIA 60 50

TUCumAN CHACOBAI

A~~~~~~~~~~~~~

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40'~~~~~~~~~~~~~~~~~~~~~~~~~~~~~0~~~~~~~~~Poet Povnes '

SaencedPovnetaitl

Naioa CpiaLUIS PIroiceBonare

\~~~~~~~~~MLS 10 2 30 400 500

t 0+0 1 dURUGUAY 0

u ~ ~ ~ ~ ~ ~ ~ ~ ~ ILMTR 0 0 00 0

O0 TIs . op s bw rpas

0~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~1

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N NEU N A R G E N T I N A

) ROO J ATERNAL,CHILD HEALTH

_4ov 0 / NEGRO + ~~~~~~~~~~~~~NUTRITION PROJECT 40.

< ~~~~~~~~~~Pro ject Provinces

t7 / qk~~~~~~~~ Selected Province Capitals

2 ; ~~CHUBUT (A N ational Copitul6 g _~~~~~~m- Province Boundaries

9 rt 6 < ~~~~~International Boundaries

d 2 ~~~~~~~~~~~~~~MILES 0 100 2 300 400 Boo

dS~ ~S N TA I ------ I2sr~~ ~ w CUZ KlLOMETeR5S 0 200 400 600 Soo

\ / ~~~~~~FALKLANDISL05ANDSi;7 ~~~~~~~(MALVINSA)

( Z \ ~~~~~~~~~~~exd for 1he corn_e¢;1 \ 5~~~t - r.nesvrt coNict(mo SOVEMlG4r, onrg "I of tedr$ ond is for 1

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APRIL 1 f92