A different approach to addressing non-communicable diseases in Argentina

Challenge

Non-Communicable Diseases (NCDs) are a major global concern. Even though they are common, NCDs are usually not detected or treated, and are often called a “silent epidemic.” They cause around 71 percent of all deaths worldwide. In Argentina, they are the leading cause of death, accounting for 63.2 percent of all deaths in 2020. NCDs affect the poor disproportionally, since lifestyle dynamics that lead to NCDs are often influenced by social and economic factors, such as poverty, lack of education, limited access to healthy food choices and safe environments for physical activity.

Approach

The Protecting Vulnerable People Against Noncommunicable Diseases Project (referred to as PROTEGER, for the Spanish word for “protect”) aimed to: (i) improve the readiness of Argentina’s public health facilities to deliver more and better NCD services for vulnerable population groups; and (ii) to protect vulnerable population groups against prevalent NCD risk factors.

PROTEGER used Transfer-Linked Indicators (i.e., the transfer of resources based on results) to incentivize its implementation at the provincial and clinic levels and, in the case of addressing risk factors, also at the municipal level. This approach was particularly suitable for Argentina’s federal structure, under which provinces and municipalities are highly autonomous. The allocation of financial resources among provinces followed a pro-poor formula, based on the proportion of people with unsatisfied basic needs (30 percent) and the provincial burden of NCDs (30 percent).

PROTEGER’s innovative design simultaneously addressed NCD care and underlying risk factors in an integrated manner, reflecting the fact that NCDs share four major risk factors: tobacco use, physical inactivity, excessive alcohol consumption, and unhealthy diets. It mirrored a paradigm shift in the approach toward NCD care, addressing them as a cluster of diseases in an integrated manner rather than in a separate, “siloed” fashion. The project’s approach toward addressing NCD risk factors was also innovative, going beyond the health sector to promote broad intersectoral responses.

Results

PROTEGER reached an estimated 1.9 million vulnerable residents with interventions that included increasing opportunities for physical activity, encouraging decreases in sodium consumption, and reducing exposure to secondhand smoke. Improved health outcomes were observed at both the national level and in participating public health clinics.

In participating public health clinics, PROTEGER contributed to the early detection and effective control of NCDs among vulnerable population groups. This is reflected in the increased capacity of these facilities to detect and control NCDs, and by the increasing proportion of NCD patients in participating public clinics whose conditions are under control. The following results were achieved over the life of the project, from

2015 to 2022:

• The percentage of participating public health clinics certified to provide quality health services for the detection and control of NCDs increased from 0 percent to 69.8 percent between 2015 and 2022.
• The number of health institutions providing new services for the early detection of colon cancer reached 877 by 2022, exceeding the target of 850.
• The percentage of vulnerable patients (i.e., those that depend solely on the public health system) regularly monitored for hypertension with an arterial pressure lower than 140/90 (i.e., the threshold between elevated and high blood pressure) increased from 6.1 to 8 percent between 2020 and 2021.
• The percentage of vulnerable patients regularly monitored for type-2 diabetes who had a HbA1c lower than 9 percent increased from 7.1 to 11.5 percent between 2020 and 2021 (HbA1c higher than 9 percent is an indicator of poorly controlled diabetes).

At the national level, PROTEGER likely contributed to the positive evolution of NCD health outcomes, even if these improvements cannot be fully attributed to this project. Overall, Argentina’s premature mortality due to NCDs declined from 20.8 percent in 2015 to 19.7 percent in 2020. Furthermore, the prevalence of NCD risk factors decreased in the 2015-2022 period. For example:

• Tobacco use among vulnerable groups decreased from 33 percent to 24.2 percent.
• There was also a significant decline in excessive sodium consumption (as defined by health guidelines) among vulnerable groups, from 29 percent to 19.9 percent.

Bank Group Contribution

Building upon the successful use of results-based financial mechanisms in previous World Bank-financed operations in Argentina’s health sector, the World Bank provided $303 million loan to finance a robust system of financial incentives for provinces, municipalities, and public clinics contingent upon the implementation of the Model of NCD Care defined by the national Ministry of Health.

Partners

Both the national Ministry of Health and the Ministries of Health of the 24 provincial jurisdictions served as key partners in PROTEGER’s success. Public health clinics and municipalities were also key partners responsible for implementing actions prioritized by the project.

Looking Ahead

Building on the knowledge and expertise gained through PROTEGER and other experiences in results-based financing, the government of Argentina and World Bank are preparing a new lending operation in the form of a Program for Results instrument. This operation is aimed at enhancing quality of care by standardizing evaluation criteria and ensuring comprehensive assessments of primary healthcare facilities, emphasizing quality, safety, and climate change considerations.

As part of the upcoming program, a new primary healthcare evaluation tool will be developed, and positive incentives will be used to encourage provinces and healthcare providers to improve the quality of services. The tool will include additional components to address emerging mental health challenges, climate change adaptation, gender-based violence, and diversity in healthcare services.