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Argentina’s Plan Nacer:
Rewarding Performance to Enable a
Healthy Start to Life
Paul Gertler
Paula Giovagnoli
SebastianMar...
Today
• What is Plan Nacer
– Origins and objectives
– Policy Mechanims
– Comparison to other models
• Evaluation
– Prenata...
Priority: Improve Birth Outcomes of
Babies Born into Poverty…
• Low Birth Weight
Associated with poor
– Health
– Education...
Argentina’s Plan Nacer
• 2002 Financial Crisis
– Many lost jobs and health insurance
• Maternal and child health
– Uninsur...
5
Incentivzed Financing Scheme
NATIONAL
GOVERNMENT
PROVINCIAL
GOVERNMENTS
Health outcomes
Enrollment
Pay for
performance
H...
Similar to Other Programs
• Examples
– Medicaid in United States
– Seguro Popular in Mexico
• Local governments responsibl...
Plan Nacer Capitation More Sophisticated
• Payment Per Enrollee
– Medicaid (100%)
– Seguro Popular (100%)
– Plan Nacer (60...
Innovative Features
• Performance Culture
– 2%-4% of health spending
– leverages existing resources
– Provide more & bette...
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...
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-...
Provincial Implementation
Enroll both facilities & beneficiaries
• Facility
enrollment
over time
0
.2
.4
.6
.8
1
Cumulativ...
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...
Today….
• Evaluation:
– Questions
– Data
– Methods
– Results
Evaluation Objectives & Methods:
Impact of a clinic enrolling in Plan Nacer on
outcomes on….
• All patients
• Beneficiary ...
Birth Certificate Data (SIP)
• Universe of births in public hospitals
– 6 northern Provinces
– 2004-08
• Very large sample...
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
...
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...
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 Nonbe...
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 Mort...
How Plan Reduced Neonatal Mortality
• Neonatal mortality all from LBW babies
• Lower by
– Preventing LBW
– Better care for...
Very Cost - Effectiveness
Lessons
• Very effective
– More & better prenatal care
– Better birth outcomes & less neonatal mortality
– Very Cost-Effec...
Evaluation Lessons
• Birth/Medical records valuable
– Large sample sizes
– Rare events
• Ability to link to admin data bas...
Many Thanks to All
Contact information:
Paul Gertler
Li Ka Shing Professor of Economics
UC Berkeley
Gertler@haas.berkeley....
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Annual Results and Impact Evaluation Workshop for RBF - State of Play of Plan Nacer - Rewarding Performance to Enable A Healthy Start to Life

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

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Annual Results and Impact Evaluation Workshop for RBF - State of Play of Plan Nacer - Rewarding Performance to Enable A Healthy Start to Life

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 13. Today…. • Evaluation: – Questions – Data – Methods – Results
  14. 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. 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. 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. 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. 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. 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. 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. 21. Very Cost - Effectiveness
  22. 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. 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. 24. Many Thanks to All Contact information: Paul Gertler Li Ka Shing Professor of Economics UC Berkeley Gertler@haas.berkeley.edu

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