secretaría de programas sanitarios

1Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF) - Workshop

Secretaría de Programas Sanitarios

Provincial Maternal -Child Health Investment

Project

Joint Health Results Based Financing (HRBF) and Spanish Impact Evaluation Fund (SIEF)

workshop


• Plan Nacer in the Argentinean Health System• Final outcomes targeted


Plan Nacer Argentina

Plan Nacer Argentina

(0,1][0,0]

1st Phase since 20052nd Phase since late 2007


Argentina's health system organization

* Estimates based on Permanent Household Survey (PHS) - INDEC

Structure of Argentine's Health System in 2008 *The Health Coverge is organized in 3 Sub-System

20,949,902

3,843,663

14,592,048

39,745,613

-

5

10

15

20

25

30

35

40

45

Social Security Private Sector Public Sector Budget Total

Popu

latio

n in

Mill

ons

52.71%

9.67%

37.62%

100%


Plan Nacer’s Share

In Population Terms

14,952,048

2,072,601

0 2 4 6 8 10 12 14 16Population in Millons

13.86%Plan Nacer

Public Sector Budget

2006/ 7 - In Expenditures Terms (mill u$s)

572

32,8

2938

0 500 1000 1500 2000 2500 3000Millons usd

5,7%

All Provincies

NE & NW

Plan Nacer

Target Population: Children under six and pregnant women, until the 45th day after delivery, who don’t have health insurance (other than the public sector budget)


Final outcomes being targeted

Contribution to the reduction of inequality in health outcomes

Contribution to the The Millennium Development Goals Evolution of infant mortality rates in Argentina

Expressed as a rate per 1,000 live birthsEvolution of Infant Mortality Gini Coefficient

Argentina 1990-2006

0.100

0.122

0.104

0.124

0.130

0.118

0.075

0.117

0.106

0.060

0.070

0.080

0.090

0.100

0.110

0.120

0.130

0.140

1990 1995 2000 2001 2002 2003 2004 2005 2006

Infa

nt M

orta

lity

Gin

i Coe

ffici

ent

25.6

22.2

16.6 16.3 16.8 16.5

14.413.3 12.9

5

10

15

20

25

30

1990 1995 2000 2001 2002 2003 2004 2005 2006

Infa

nt M

orta

lity

rate


The National Government have embarked on a new kind of relationship with the Provinces to coordinate efforts in health provision

To strengthen the Public Health Subsystem in particular the Primary Healthcare Network

To increase accessibility and improve quality of health care (effective coverage)

To Contribute to the reduction of maternal and infant morbimortality rates

Plan Nacer´s Main Goals


Coverage Rate Evolution by Region NE and NW Regions

NE; August-08: 81%248.515 Beneficiaries

NW; August-08: 77%275.644 Beneficiaries

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

April

- 05

Aug -

05

Dec -

05

April

- 06

Aug -

06

Dec -

06

April

- 07

Aug

-07

Dec -

07

Jan -

08

Feb-

08

Mar-0

8

April

-08

May-0

8

Jun-

08

Jul-0

8

Aug -

08

Sep -

08*

Oct-0

8*

Nov-0

8*

Dec-0

8*

NE NW APL1

PROVINCIAL GOAL OBSERVED DATA

Dec-2008* 89%Beneficiaries Target NE 274.380 NW 321.271 Total 595.651

Total August-08: 79%524.159 Beneficiaries


Beneficiaries by region / Investment :

PATAGONIA29.680 Sept ´08

76.035 Target

Total Investment

1st Phase USD 135.8 MM (70% used) since 2005

2nd Phase USD 300 MM (5% used) since late 2007

Total Beneficiaries 897.219 - Sept-091.4 MM have been enrolled in the Plan Nacer

since de begining of de Program

CENTRO269.657 Sept ´08

1.053.288 Target

CUYO73.974 Sept ´08

188.660 Target

NOA274.253 Sept ´08

359.189 Target

NEA249.655 Sept ´08

307.455 Target


Health Providers by Region– August 2008

PATAGONIA353

Total Providers with Agreement

4.061

CENTRO1.351

CUYO490

NOA1.054

NEA813


Principal – Agent Framework Main Actors of the strategy

PROVINCES SERVICE PROVIDERS

Maternal-Child insurance Unit Primary Health Care Centers and Maternity Hospitals

ENROLLMENT Final Validation of Beneficiaries databases

Identification and enrollment of eligible population

Enrollment and follow up beneficiaries

NOMENCLATURE Design and definition of a package of basic healthcare practices

Define the pricing policy for a group of basic practices

Provision and billing of health care services

Provide Financial Resources: Use of funds in:g Human resourcesg Equipmentg Infrastructureg Inputs

Supervision and Monitoring of: g Beneficiaries Database Services renderedg Tracers Tracersg Services rendered

Hiring and payment of services covered

Unique bank account managementPAYMENT

MECHANISMS

AUDITING Medical history registration

Mana

gem

ent c

omm

itmen

t - L

egal

Fra

mew

ork

Agre

emen

t - L

egal

Fra

mew

ork

NATIONAL GOVERNMENT

• 60% linked to the identification and registration of eligible population

(enrollment)

• 40% linked to the fulfillment of specific health goals (tracers) -

Includes setting of healthcare goals through mother-child indicators

Roles \ Actors


Plan Nacer’s Payment Mechanism

National Level

Provincial Level

Target Population

Providers

Capitation split in 2 Result Based-Financing

(RBF)

Fee for Service

Use of nomenclature (Primary Health care

Practices)

60% Enrollment

40% HealthOutcomes(Tracers)

Change in health outcomes


Principal-Agent Relationships with asymmetric information predicts opportunistic behavior

NATION (PRINCIPAL) - PROVINCE (AGENT)

PROVINCIAL LEVEL OPPORTUNISM

Funding crowding out of spending Pre contract opportunism (hiding information when defining targets) Post contact opportunism (shirking effort & hiding information to

avoid higher targets in future periods)

PROVINCE (PRINCIPAL) - HEALTH PROVIDER (AGENT)

HEALTH PROVIDER LEVEL OPPORTUNISM

Misuse of practices Overbilling of high prices practices (delivery) Potential fraudulent overbilling

Theoretical Framework


Principal-Agent Relationships with asymmetric information predicts opportunistic behavior

PROJECT RESPONSES

Change in the results’ payment scheme

Stakeholder approach to monitor and put credible monitoring threats (coordinate different principals guide in the provider’s effort), it includes beneficiaries empowerment: Social Control

Monetary sanctions firmly applied

Strengthening and directing Auditing Activities (External Concurrent Auditing and Internal Auditing and Supervision, National and provincial level auditing organisms)

Theoretical Framework


Change in the incentives’payment scheme

Incentives payment function

From: All-or-nothing

To: Flexible or continuous

(3 thresholds scheme)

0%

1%

2%

3%

4%

5%

LS ij

% Trans. Mensual Base

Thresholds rule has better incentive properties in terms of avoiding opportunistic behavior

0%

1%

2%

3%

4%

0 1 CAij/ Dij

% Trans. Mensual Base


The need to define a model for institutional change

Resources

Policy Consensus

Conflict Zone

Result Based-Management

Steering Role


Bureaucratic Model New Model in Public Management

Rule fulfilment

Central Intervention

Focus on implementation

Focus on formal fulfilment

Closed information system

Incentives

Decentralized responsibility

Focus on impact

Focus on user performance and satisfaction

Transparency and Social Oversight

Focus on inputs Focus on the Performance

New Paradigm in Public Management


Specific Health Goals: Plan Nacer Tracers

N° HEALTH GOALS DESCRIPTION

I Early detection of pregnant women Detection before the 20th week of pregnancy

II Effectiveness of childbirth and neo-natal care Newborn's physical condition after delivery (APGAR - Appearance, Pulse, Grimace, Activity, Respiration- score > 6 at 5 minutes after birth )

III Effectiveness of prenatal care and prevention of pre-maturity Infants weighing more than 2500 g

IV Effectiveness of prenatal care and childbirth care VDRL -Venereal Disease Research Laboratory- test and immunization for mothers against tetanus

V Audit of mother and child deaths Audit process in case of mother or child death seeks to evaluate and improve the current level of care

VI Immunization coverage Triple viral and measles immunization for children under 18 moths

VII Sexual and reproductive care Provision of information on contraceptive and sexual health services during puerperium

VIII Follow-up of healthy children up to one year old Provision of health care and checkups for children up to one year old

IX Follow-up of healthy children from 1 to 6 years of age Provision of health care and checkups for 1 to 6 year old children

X Inclusion of indigenous communities Health care provision for indigenous population


Funds Transfers – August 2008

Total Transfers 1st Phase since 2005USD 60,261,148

Total Transfers 2nd Phase since late 2007USD 11,994,026NEA

USD 28,839,214

NOAUSD 31,421,935

CUYOUSD 2,714,473

PATAGONIA USD 811,873

CENTROUSD 8,417,679


Nomenclature’s Practices

g Health Education Consultation during pregnancyg Papanicolau and Colposcopyg Antitetanic Vaccine g High-risk Pregnancy consultationg Human immunodeficiency virus (HIV) care during pregnancy g Deliveryg Cesareang Measles immunizationg Puerperium counseling g Immunization of the new-born childreng Incubator up for a period of 48 hoursg Immediate treatment in case of HIV vertical transmission g Ophthalmologic consultationg Follow-up consultationg Dental care counselingg Pregnancy testg Colposcopy in pregnant controlg Blood extractiong Blood testg Thoracic XRg Ecographyg Detection of pregnant women in their first quarter of pregnancy by sanitary or health care agents g Round of sanitary agent in rural area g Socio – Epidemiologic diagnosis of population at risk g Reunions for feeding guidelines promotion g Infant development promotion meetings g Newborn emergency transportation serviceTransport

Children

GROUP AND SUBGROUP

Woman

EXAMPLE PRACTICES

Community

Images

Laboratory

Pregnant Woman

High risk Pregnancy

Delivery

Puerperium

Neonate

Infants under 6 years old


Nomenclature’s Practices

GROUP AND SUBGROUP1st Phase

Practices Amount

Woman

Pregnant Woman 6,5% 5,4%High risk Pregnancy 0,4% 0,7%Delivery 1,7% 30,2%Puerperium 2,5% 2,3%

ChildrenNeonate 1,1% 1,9%Infants under 6 years old 49,8% 46,1%

Laboratory 11,9% 4,6%Images 2,1% 2,4%Community 8,4% 4,5%Transport 15,6% 2,0%TOTAL 100,0% 100,0%

Group and Subgroup practices: Percentage Structure August- 2008


Inscription Monitoring by Province DepartmentsProvince: Misiones

Inscription Coverage Rate ranged by Infant Mortality Rate August 2008

88%

64%

94%

77%82% 84%

94%

75%

89%

95%90%

86%90%

93%88%

98%

87%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

San

Javie

r

Conc

epció

n

Mont

ecar

lo

Lean

dro

N. A

lem

Ober

á

Iguaz

ú

Guar

aní

Após

toles

San

Ignac

io

Cand

elaria

Caing

uás

Gene

ral M

anue

lBe

lgran

o

25 d

e Ma

yo

San

Pedr

o

Liber

tado

r Grl.

San

Martí

n

Capit

al

Eldor

ado

Range 5,4 - 12,9 Range 13,4 - 16,8 Range 18,1 - 26,6Source: DEIS 2006


Tracer I Evolution: Early Detection of Pregnant Women

Evolution Tracer I: Early Detection of Pregnant womenNE - NW - 1 st Phase

5,7% 4,5%

11,4%

35,9%

49,9%

23,4%

38,0%

19,1%

44,2%

53,3%57,9%

37,2%

4,0% 4,6%7,0%

13,9%

23,5%

27,1%

39,9%

45,9%

53,7% 54,7%

4,7%

23,6%

36,5%

2,3% 3,0%

8,9%

19,3%

36,0%

42,3%

54,1%

51,9%

0%

20%

40%

60%

80%

100%

II-2005 III-2005 I-2006 II-2006 III-2006 I-2007 II-2007 III-2007 I-2008 II-2008 III-2008*

Average NE Average 1 st Phase Average NWIII - 2008*: Projection


Tracer II Evolution: Effectivenss of Childbirth and Neo Natal Care

Evolution Tracer II: Effectiveness of Childbirth and Neo - Natal CareNE - NW – 1st Phase

24,0%25,3%

4,6%

39,4%

15,0%

48,8%

72,5%69,2% 66,5%

90,8%87,7%

20,3%

30,5%

8,5%

36,5%

89,0%

71,9%

98,9%

87,8%

70,5%

50,9%

69,8%

12,2%

36,6%

97,2%97,2%

87,9%

33,7%

52,8%

68,8%

74,3% 72,8%

0%

20%

40%

60%

80%

100%

II-2005 III-2005 I-2006 II-2006 III-2006 I-2007 II-2007 III-2007 I-2008 II-2008 III-2008*Average NE Average 1 st Phase Average NWIII - 2008*: Projection


Tracers Monitoring by Province DepartmentsProvince: Córdoba

Tracers Analysis by Department(Every four months)

Tracers I, II, III, IV are related with pregnancy and delivery

I By Dep II By Dep III By Dep IV By DepCalamuchita 8 1,6% 58 1,5% 58 1,6% 29 1,0%Capital 80 15,8% 1530 40,9% 1389 39,3% 1341 46,9%Colón 36 7,1% 187 5,0% 184 5,2% 118 4,1%Cruz del Eje 43 8,5% 198 5,3% 191 5,4% 183 6,4%General Roca 3 0,6% 19 0,5% 21 0,6% 18 0,6%General San Martín 32 6,3% 185 4,9% 168 4,8% 86 3,0%Ischilín 6 1,2% 44 1,2% 43 1,2% 5 0,2%Juárez Celman 8 1,6% 37 1,0% 41 1,2% 36 1,3%Marcos Juárez 7 1,4% 26 0,7% 24 0,7% 13 0,5%Minas 1 0,2% 2 0,1% 2 0,1% 1 0,0%Pocho 0 0,0% 0 0,0% 0 0,0% 0 0,0%

Pte. Roque Sáenz Peña 4 0,8% 41 1,1% 41 1,2% 4 0,1%Punilla 71 14,0% 269 7,2% 254 7,2% 162 5,7%Río Cuarto 38 7,5% 512 13,7% 474 13,4% 479 16,7%Río Primero 13 2,6% 5 0,1% 10 0,3% 2 0,1%Río Seco 0 0,0% 0 0,0% 0 0,0% 0 0,0%Río Segundo 14 2,8% 33 0,9% 32 0,9% 27 0,9%San Alberto 6 1,2% 15 0,4% 14 0,4% 13 0,5%San Javier 9 1,8% 114 3,0% 112 3,2% 95 3,3%San Justo 42 8,3% 158 4,2% 172 4,9% 139 4,9%Santa María 10 2,0% 136 3,6% 128 3,6% 4 0,1%Sobremonte 7 1,4% 0 0,0% 1 0,0% 1 0,0%Tercero Arriba 4 0,8% 60 1,6% 63 1,8% 0 0,0%Totoral 6 1,2% 0 0,0% 0 0,0% 0 0,0%Tulumba 2 0,4% 1 0,0% 1 0,0% 1 0,0%Unión 57 11,2% 115 3,1% 111 3,1% 103 3,6%Sin Especificar 0 0,0% 0 0,0% 0 0,0% 0 0,0%

Total Córdoba 507 100,0% 3.745 100,0% 3.534 100,0% 2.860 100,0%

DepartmentTracers I four month period-2008


Use of Funds Monitoring by Province Province: Corrientes

Use of Funds by Providers - 1st PhaseAmount of funds spent up to June 2008 : USD 28,401,147.35

Maintenance and Investment

30,5%

Medical Inputs7,2%

Professional Services24,7%

Others11,7%

Incentives25,9%


A change in payment mechanism is mainly a change in the way the different actors relate with each other in a public policy

This may bring important changes in how to achieve health outcomes

In this change data accuracy play an important role

Uncertainty and asymmetric information is the natural context we must deal with.

Main Lessons


To encourage health teams to provide integral health care coverage

Strengthening decentralized monitoring capabilities and steering role of the provinces

Generalize the payment mechanism in terms of expenditures in the public health system

The national goverment decided to include a high complexity practice in the Plan Nacer Nomenclature: Congenital Heart Disease Surgery

Challenges


Plan Nacer Impact Evaluation. Main Objectives

1. To measure the change in the Health Care Facilities’ behavior that provide Primary Health Care to eligible population when facing the new payment strategy introduced by the Plan Nacer.

2. To measure the impact in coverage and quality of the health care services provided to pregnant women and children under 6 yeas of age

3. To measure the change in Health outputs and outcomes in pregnant women and children under 6 yeas of age as a result of the introduction of the program


2005 2006 2007 2008 Dec 2008

1st Method: a Household

Survey

3 Party TEAM …P.NACER+WB+CEO

P:1st STRATEGY

Jun 05

Baseline 1st Phase

Oct 06 Feb 07

Feb 06

Oct 07

New Strategy to measure causality:

Instrumental variables – Pilot

Survey

Baseline 2nd Phase

I.E.

Plan Nacer

Provinces start to Enroll

Jun 05

All Provinces are included -

Provinces start to Enroll

Jun 07

Provinces start Payment

Mechanism

Plan Nacer and itsImpact Evaluation Strategy in time

Payment mechanisms start

in 2nd Phase


Time line of the impact evaluation

We plan 3 moments in the evaluation process:

1. Moment 0 Corresponds to the baseline measurement

2. Moment 1 To measure the intermediate impacts of the program (scheduled for 2009/2010)

3. Moment 2 To measure the final impacts of the program (scheduled for 2011/2012)


Specific objectives

1. Sampling design and selection of providers and eligible population in their catchment area (in the provinces adherent to the Plan Nacer).

2. Sampling design and selection of a control group

3. Design of questionnaires to gather data

4. Data gathering at households, health facilities, medical records and specific measures of anemia, height and weight

5. Data base organization of the collected data to permit the follow up of treatment and control groups


Sampling technique

• Representative at provincial level Both

requirements were fulfilled

• Sample power to capture change

• A multi-stage stratified sampling procedure was implemented to select localities, then providers and finally the eligible population in their catchment area


Propensity score matching between localities in provinces of the 1st Pahse and localities in sorrounding provincies : • Dependent variable: Y=1, treatment; Y = 0, not treatmet

• We used available data at locality and facility levels as indipendent variables (sources: Population Census 2001 and Remediar Plan providers` list. Both constitute the sampling frame).

• A probability (p) was estimated to pair localities.

Locallities were paired and we had a balanced treatment and control groups

Statistical tests were applied to evaluate the sample power

A first attempt to capture causality in 1st Phase


A first attempt to capture causality in 1st Phase

• Multi-stage sampling and Propensity Score Matching allowed to select the localities’ sample

• Within the localities sample a providers’ sample was selected (60 providers in each province)

• For each provider a sample of 10 households was selected (eligible population with the latest child born in the previous 13 months


Difference in differences

• We planned a panel survey in moments 1 and 2 to obtain a difference in difference estimates of the change in main output and outcome indicators using a regression equation like the following one:

y = 0 + 1d + 2t + 3(dt) + X + v

Where:• Y: is an output or outcome variable • d: is 1 if the person is a beneficiary of the program and 0 if the

person belongs to the control group• t: is 1 in moments 1 or 2 and 0 in the baseline• dt: is 1 if the person is beneficiary in moments 1 or 2 and 0 in

other cases• X: Vector of variables that affect and• v: random variable.


Sample Sizes

Planned Sample Sizes in Plan Nacer´s Impact Evaluation

PER PROVINCE TOTAL PER

PROVINCE TOTAL

PHASE 1 9 167 60 540 600 5,400

PHASE 2 15 251 60 900 600 9,000

TOTAL 24 418 1,440 14,400

PHASE PROVINCES LOCALITIESPROVIDERS HOUSEHOLDS


Other eligible Children

- Questions about the type, quality and satisfaction of services received andname of the health care agent providing care

Mother

Last Child Born (aged between 1 and 12

months)

Managers

Doctors

Exit Poll

- Information on the newly-born child shall be provided by the mother or personin charge of nursing the child

Hous

ehol

d Su

rvey

- Household usual socio-demographic indicators. History of pregnancies andchildbirths

Spec

ific

Med

ical

Rec

ords

- Questions related to three-four hypothetical visits to learn about good practice protocols.

Medical records recovery at the PHC Facilities

- Measuring encephalic perimeter - Measuring height

- Measuring weight

Specific measures taken in the field (to the mother

and the latest born child)

- Weight and height - Contraceptive methods - Last visit of the child, PHCC he attended, name of the health agent

- Anemia test (Hemo cue)

- Child's APGAR index

- General features of the center (staff, infrastructure, equipment, inputs, resources, expenditures and sources of funds)

- Demographic and Labor and professional qualifications

- Questions related to their attendance to the center - Socio-economic questions

- In PHCCs, number of consultations per type of patient (age, gender) and reason, per month during the last year.

- Reconstruction of medical care received

Serv

ice

Prov

ider

s

- Mother's aerobic capacity; contraceptive methods; practices of hygiene and healthy behavior

- Information on the latest pregnancy and childbirth- Weight and height of the mother and the child, child's APGAR index; mental

health

- Checklist all the contents of the medical records

Questionnaires contents


• The national coverage of the program in 2007 required a new strategy to capture causality

• We chose a randomized promotion at locality level

• The randomized promotion design focuses on the effect of the program on beneficiaries. For outcomes two and three (impact in providers behavior), a number of alternatives are being considered

New Strategy: Instrumental Variables


• The promotion should satisfy the following sufficient and necessary conditions to qualify as a valid instrumental variable:

• A pilot survey was implemented to verify the fullfiment of the conditions and to compute sample power analysis (oct-2007)

1. Being correlated with program enrollment2. Not being correlatedthe the error term (other features of

the population)3. Only affecting health results through Plan Nacer

interventions

Randomized Promotion Design


• We want to learn more about the design of the providers incentives mechanism and its impact in the use of Primary Health Care practices that hits in health outcomes and prevent billing opportunism

• Promoted localities follow up to enhance the quality of the Instrumental Variable

• Adequate design of moments 1 and 2 to better capture the Plan Nacer´s impact

• Diffusion of survey results and knowledge

Methodological challenges


2009 2010 2011 2012 Dec 2012

1st Phase : Randomizad promotion for pregnant women2nd Phase : Baseline

Midterm Ealuation

causality to learn about providers behaviour

Final Impact Evaluation 1st

PhaseI.E.

Plan Nacer

End of 1st

Phase

1st Phase: • Provinces fund 30% of the USD 5 per beneficiary

2nd Phase: • Improve use of practices • Monitoring use of funds

Plan Nacer and itsImpact Evaluation prospective time-line

End of 2nd

Phase

Final Impact Evaluation 2nd

Phase

DIVULGE RESULTS


A two level incentives system

NATION - PROVINCE

Relationships

PROVINCE - PROVIDER

Payment for enrollment

Payment for health outcomes

Payment for PHC practices billed

Decision of final use of funds

Principal – Agent Framework


Coverage Rate EvolutionNE Region

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

April

- 05

Aug -

05

Dec -

05

April

- 06

Aug -

06

Dec -

06

April

- 07

Aug

-07

Dec -

07

Jan

-08

Feb-

08

Mar-0

8

April

-08

May-

08

Jun-

08

Jul-0

8

Aug -

08

Sep

- 08*

Oct-0

8*

Nov-

08*

Dec-

08*

CorrientesChacoFormosaMisionesNE

Provincial Goal

secretaría de programas sanitarios

Documents