A presentation from the 2014 Annual Results and Impact Evaluation Workshop for RBF, held in Buenos Aires, Argentina.

1. Argentina’s Plan Nacer:
Rewarding Performance to Enable a
Healthy Start to Life
Paul Gertler
Paula Giovagnoli
SebastianMartinez
March 2014
Buenos Aires, Argentina

2. Today
• What is Plan Nacer
– Origins and objectives
– Policy Mechanims
– Comparison to other models
• Evaluation
– Prenatal Care & Birth Outcomes
– Evidence from 7 northern Provinces

3. Priority: Improve Birth Outcomes of
Babies Born into Poverty…
• Low Birth Weight
Associated with poor
– Health
– Education
– Earnings
• Uninsured & little access to quality care

4. Argentina’s Plan Nacer
• 2002 Financial Crisis
– Many lost jobs and health insurance
• Maternal and child health
– Uninsured
– Access to quality care
• Mechanisms
– Uninsured use of public facilities
– More money to public system

5. 5
Incentivzed Financing Scheme
NATIONAL
GOVERNMENT
PROVINCIAL
GOVERNMENTS
Health outcomes
Enrollment
Pay for
performance
HEALTH
FACILITIES
Fee for
service
Umbrella Agreements
EXTERNALAUDIT
Provincial
Health Insurance
PerformanceAgreements
EXTERNALAUDIT
Facility
decides on
use of funds

6. Similar to Other Programs
• Examples
– Medicaid in United States
– Seguro Popular in Mexico
• Local governments responsible
for care of uninsured (poor)
– Co-financed with national government
– Capitation payment per enrollee

7. Plan Nacer Capitation More Sophisticated
• Payment Per Enrollee
– Medicaid (100%)
– Seguro Popular (100%)
– Plan Nacer (60%)
• Plan Nacer Adds Performance Incentives
– Health outcomes, Utilization & quality
– Up to 40% of max payment

8. Innovative Features
• Performance Culture
– 2%-4% of health spending
– leverages existing resources
– Provide more & better care without more money
• Nation to Province
– Performance Incentives (Health Outcomes)
• Incentive payments to providers for services

9. Provinces did a good job of meeting
Performance Target (70-80%)
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
2005-2 2005-3 2006-1 2006-2 2006-3 2007-1 2007-2 2007-3 2008-1 2008-2

10. 0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
2005-2 2005-3 2006-1 2006-2 2006-3 2007-1 2007-2 2007-3 2008-1 2008-2
Total Payments Nation to Provinces (Blue) and
Performance Payments (Red)

11. Provincial Implementation
Enroll both facilities & beneficiaries
• Facility
enrollment
over time
0
.2
.4
.6
.8
1
CumulativeProbability
2004q3 2005q3 2006q3 2007q3 2008q3
Quarter
c.d.f. Normal c.d.f.

12. Beneficiary Enrollment
Children Mothers
0
100,000
200,000
300,000
400,000
500,000
600,000
2004 2005 2006 2007 2008
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
2004 2005 2006 2007 2008

13. Today….
• Evaluation:
– Questions
– Data
– Methods
– Results

14. Evaluation Objectives & Methods:
Impact of a clinic enrolling in Plan Nacer on
outcomes on….
• All patients
• Beneficiary patients
• Non-beneficiaries patients
Take advantage of phasing in
geographically over time

15. Birth Certificate Data (SIP)
• Universe of births in public hospitals
– 6 northern Provinces
– 2004-08
• Very large sample sizes
• Important for rare outcomes
– Low Birth weight
– Neonatal mortality

16. Plan Nacer Increases Prenatal Care Use
4.4
5.9
3.6
0
1
2
3
4
5
6
7
Number of PrenatalCare Visits
0.59
0.75
0.54
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
Share InitiatingPrenatalCare
Before20 weeks

17. Plan Nacer Increases Prenatal Care Quality
0.78
0.84
0.78
0.75
0.8
0.75
0.7
0.72
0.74
0.76
0.78
0.8
0.82
0.84
0.86
Control Beneficiaries nonbeneficiaries
Tetanus Vaginal Delivery

18. Plan Nacer Reduces Low Birth Weight
0.073
0.059
0.073
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
Control Beneficaries Nonbeneficiaries

19. Plan Nacer Reduces Neonatal Mortality
0.062
0.029
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
Control Beneficiaries
Neonatal Mortalityof LBW
Babies0.0095
0.0025
0
0.001
0.002
0.003
0.004
0.005
0.006
0.007
0.008
0.009
0.01
Control Beneficiaries
OverallNeoNatalMortality
Series1

20. How Plan Reduced Neonatal Mortality
• Neonatal mortality all from LBW babies
• Lower by
– Preventing LBW
– Better care for LBW babies
• Find
– 54% of reduction from preventing LBW
– 46% from better care for LBW babies

21. Very Cost - Effectiveness

22. Lessons
• Very effective
– More & better prenatal care
– Better birth outcomes & less neonatal mortality
– Very Cost-Effective
• Innovative
– Incentives leveraged small in funding (2-4%)
– Changed the culture

23. Evaluation Lessons
• Birth/Medical records valuable
– Large sample sizes
– Rare events
• Ability to link to admin data bases
– Where get care & programs
– Program beneficiaries
• Cheaper & faster

24. Many Thanks to All
Contact information:
Paul Gertler
Li Ka Shing Professor of Economics
UC Berkeley
Gertler@haas.berkeley.edu