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

3. Plan Nacer and Programa SUMAR
Moving Forward towardsEffective
Universal Health Coverage
Dr. Martín Sabignoso
National Coordinator Programa SUMAR
RBF Workshop
March 2014, Buenos Aires, Argentina
2004-2014
A 10-year-old RBF experience

4. Context
Nation Stewardship role
Primarily responsible
for the provision of
health care
Provinces
Federal
Organization
ARGENTINA
after the
worst crisis
2002
Half the populationwithout social or
privatehealth insurance (48%)
65% of childrenuninsured
IMR 16.8 (per 1000)and 22 (per 1000)in
the Nothern Region
Gaps in access to health services

5. To strengthen a debilitated and overburdened health
system after the 2001 crisis
To transform the existing coverage into effective
coverage
To reach better and more equitable results with the
available resources
Why Plan Nacer?

6. Plan Nacer ´s
goals and target
population

7. Plan Nacer´s Goals and Objectives
Before
Plan Nacer
• Implicit universal
public coverage
• Financed through
public budget
• Quality and
coverage gaps
With
Plan Nacer
• Explicit coverage
of prioritized
services for the
population without
formal insurance
• Additional
investment
through RBF to
bridge the
observed rated
gap
• Quality-driven
strategy
Intermediate Objetive
Increase access and
quality of prioritized
healthservices
Final Objetives
Improve the health
status of population
Increase
satisfaction

8. 10 Million
Eligible
Population
without formal
insurance
Gradual Implementation
2005 - Phase 1:
PLAN NACER
pregnantwomen
and children 0-6
2012 - Phase 2:
PROGRAMASUMAR
women 0-64
and men 0-19
2016 - Phase 3:
women 0-64
and men 0-64

9. Gradual Implementation
Evolution of Enrollment
Dec 12:
1,957,407
100%
Dec 13:
8,218,736
83%An increase of more than 5
million in 3 months

10. Plan Nacer ´s
Pay for Perfomance
Mechanisms

11. Results-Based Financing
NATION
Sets a per
capita value
USD2.5
PROVINCE
Health performance
indicators - Tracers
(every four months)
Enrollment
(monthly payment)
Capitationpayment basedon performance
Provincial
Health Insurance
UmbrellaAgreement
External and internalverification
Resourses are
transferred to a
separate bank
account
I. Early detection of pregnant women (before
week 20 of gestation)
II. % of newborns with APGAR score > 6 at 5
minutes
III. % of newborns with birth weight > 2,500g
IV. % of mothers with VDRL and anti-tetanus
vaccine
V. Medical auditing of maternal and infant
deaths
VI. % of children <18 months of age with
triple viralvaccine
VII. % of mothers who received counseling
on contraceptive and sexual health
VIII. % of children <1 year of age with health
check-ups according to protocol
IX. % of children 1 to 5 years of age with
health check-ups according to protocol
X. % of providers qualified on the care of
indigenous population
PLAN NACER TRACERS

12. Results-Based Financing
PROVINCE HEALTH PROVIDER
Fee for
Service
(monthly payment)
Provincial
Health Insurance
PerformanceAgreement
External and internalverification
Autonomyin the
use of funds
The Nationdefines
the list of authorized
health services and
each Province sets
the prices.
The facility is
assigned a bank
accountwhere it
will receive the
funds
The facility may self-
manage its own account
or it may be managed by
a third party (hospital,
local secretariat,
municipality)
The province or
municipality defines
the expenditure
categories according
to the program´s rules.
The facility decides
which specific goods
or service to purchase.
USE OF FUNDS
•Staff Incentives
•Staff hiring and
training
•Supplies
•Investment
•Maintenance
The provider
has up to 4
monthsto
bill the
services

13. Results-Based Financing
NATION
Sets a per
capita value
USD2.5
PROVINCE
Health outcomes –
Tracer indicators
(every four months)
Enrollment
(monthly payment)
Provincial
Health Insurance
HEALTH PROVIDER
Fee for
Service
(monthly payment)
Stewardship
Autonomy
Consensus
Capitationpayment basedon performance
USE OF FUNDS
•Staff Incentives
•Staff hiring and
training
•Supplies
•Investment
•Maintenance
BALANCE

14. Virtuous cycle promoted by the Program
1. Health care is providedto the
population
2. Health professionals
completethe medical records
3. Administrative staff
bill the health services.
Eachprovince develops
its ownIT system.
6. Additionalresources
for health providers
4. Verification and Payment
• Tracer measurement
7. Improvementsin health care
5. Ex post Verification
7 steps

15. Gradual Scale-up
Plan Nacer´s Health Care Coverage
Prevention and
Promotion
CongenitalHeart
disease Surgery
Treatment of
Prevailing
Pathologies
HighComplexity
Perinatal Care
Health Interventions
for children,
adolescents and
women
100
health services
400
health services

16. MEDICAL CONSULTATION
IMMUNIZATION
PRACTICES
LABORATORY
ANATOMIC PATHOLOGY
IMAGES
COUNSELING
COMMUNITY INTERVENTIONS
HOSPITALIZATION
TRANSPORT
FIRST PRENATAL MEDICAL VISIT AND FOLLOW-UP
- PEDIATRIC CHECK UP
INFLUENZA VACCINE IN PREGNANCY
HEPATITIS A IN CHILDREN
PAP SMEAR SAMPLING
OAE SCREENING FOR HEARING LOSS IN NEWBORNS
GROUP FACTOR, HEMOGLOBIN, BLOOD GLUCOSE,
COMPLETE URINE, VDRL, CHAGAS, HIV
READING OF PAP SAMPLE
OBSTETRIC ULTRASOUND
ROUND OF SANITARY AGENT IN RURAL AREA
PROMOTION OF HEALTHY HABITS WORKSHOPS
COUNSELING IN SEXUAL AND REPRODUCTIVE HEALTH
DURING PUERPERIUM
FIRST TRIMESTER BLEEDING TREATMENT
INCUBATOR FOR NEWBORNS (UP TO 48 HOURS)
NEWBORN AND HIGH RISK PREGNANT WOMEN
EMERGENCY TRANSPORTATION SERVICE
1
2
3
4
5
6
7
8
9
10
Plan Nacer´s Health Care Coverage

17. Plan Nacer´s Health Care Coverage
Mandatory registration in medical record
Non-mandatory but desirable, will be mandatory in the short run
Non-mandatory but desirable
Quality Attributes
Health
services
First Prenatal
check-up
MANDATORY: Registry in MR,
height, weight, blood
pressure, body mass index,
risk assessment
NON-MANDATORY but
desirable: Memory test
Mandatory report
for billing
Source
for tracers

18. Plan Nacer´s Health Care Coverage
Quality Attributes
Health
services
Pediatric check-up
MANDATORY height, weight,
percentiles, blood pressure, body
mass index
NON-MANDATORY but desirable:
visual acuity test, psycho-maturity
assessment
Source
for tracers
Mandatory registration in medical record
Non-mandatory but desirable, will be mandatory in the short run
Non-mandatory but desirable
Mandatory report
for billing

19. Progress in health care coverage
27,967
1,190,374
3,248,702
5,322,308
7,042,292
7,720,791
9,545,073
10,060,728
2005 2006 2007 2008 2009 2010 2011 2012
46 million health services
billed between 2005 - 2012
Paper based Digital
81% of health
services are billed online
The billing incentivescheme
promotes and improvesthe
quality of clinical records and
timely reporting
Availalable Clinical Records
2005: 2.8 over 10
2012: 9 over 10

20. How do health facilities invest their
recourses?
Autonomy
Total Country – Accumulated valuesto October 2013
Maintenance

21. Total Country- Accumulated Values October 2013
8 Provinces with Staff
incentives
16 Provinces without
Staff incentives
Autonomy
The National Program
establishes that staff
incentivesmust
represent< 50% total
funds
.
In the province of Buenos Aires,
staff incentives are capped at 25%
at municipality level
Maintenance
Maintenance

22. Cholila
Rural Hospital
(Province of Chubut )
New fitness center
for elderly women to
prevent a sedentary
lifestyle and to help
during the treatment
of chronic diseases.
The entire community benefits from Plan Nacer funds
Autonomy

23. Autonomy encourages creativity
Autonomy
Santa Rosa
Health Center
(Province of La Pampa)
At Christmas, the
health center draws
bicycles for all those
children whose
vaccines and checkups
are up to date. The
bicycles are purchased
with Plan Nacer funds.

24. What do health teams value?
1. Improved organization
2. Improved professional practice
3. Increase in coverage
4. Improved workplaces
TESTIMONIOSPN - SUMAR2013subt.wmv
67,2
Index
Satisfaction
Northern
Region
Increase in Health Team Motivation
7370
Facilities
participating

25. Plan Nacer ´s
Verification Scheme

26. Concurrent  All
year in the field
Bimonthly
reports
Risk -
based
sampling
Binding
Financial and
medical
Suggests adjustments
and penalties
External Internal
Financial
and
medical
Training
approach
Supervisor
Third party
Verification Scheme
National and
Provincial
Debits and fines are
imposed when there are
errors andmisreporting in:
1. Roster information
2. Billing and payments to
health facilities
3. Tracers

27. Independent Verification Scheme
65% penalties due to tracers
Period 2005 – 2012
18.8 million total cost of external verification
USD12,300 average monthly cost per province
17.9 million in debits and fines 6% of total
capitation transfers
(USD 310.7 million)
Main contributions of the external verification:
 It strengthens control environment and transparency.
 It improves the regulatory framework.
 It promotes best practices and quality standards of care
and organization among health providers.

28. Improvement in tracer reports
Percentage of rejection of tracer cases
I 8% 9% 8% 9% 19% 15% 6% 16% 12%
II 2% 7% 5% 3% 8% 6% 1% 2% 2%
III 3% 8% 6% 4% 8% 6% 1% 2% 2%
IV 5% 14% 10% 9% 18% 15% 2% 8% 6%
V 1% 26% 12% 0% 5% 3% 1% 8% 5%
VI 7% 8% 8% 7% 7% 7% 7% 7% 7%
VII 6% 22% 15% 6% 19% 14% 1% 6% 4%
VIII 6% 4% 5% 9% 5% 7% 4% 7% 5%
IX 26% 6% 15% 12% 5% 8% 9% 12% 11%
X 5% 7% 6% 1% 8% 5% 1% 1% 1%
Average 7% 11% 9% 6% 10% 9% 3% 7% 6%
% Country
Tracer
2008 2010 2012
% Phase 1 % Phase 1 % Phase 1% Phase 2 % Phase 2% Country % Country % Phase 2
Total
number
of cases
reported
1,682,381 2,194,909 3,777,775
The number of cases more than doubled in the period! (+125%)

29. Ongoing learning,
Innovation and
improvement

30. Incentive payments function
All or nothing
0%
1%
2%
3%
4%
LS ij
0%
1%
2%
3%
4%
0 1
CAij/ Dij
% monthly payment
% monthly payment
ADVANTAGES
• Incentives for all the provinces, every
improvement counts.
• Partial retribution for “partial achievement”,
always promoting the optimal result.
• Balance any baseline deficit.
Changes in the retribution scheme of health
outcomes – Plan Nacer Tracers
Continuous function
with 3 thresholds

31. Impact of changes in the retribution scheme
Plan Nacer Tracers
 33%
All or nothing Continuous

32. NEW SCHEME
60% Capitation
Payment
Enrollment
+
Service provided
Last 12 months
‘Every achievement
poses a new challenge’
December 2012
100% of the population
were enrolled but 27% did
not have a health service
reported in the previous
year.
Ongoing Improvement Process

33. Results-Based Financing
New Performance Indicators
Used to evaluate provincial systems

34. 2004 - 2012
Pregnancy Care
before week 20th
86%
since 2013
Pregnancy Care
before week 13th
51%
More demanding indicators
‘Challenging the status quo
and pushing the limits’
Ongoing Improvement Process

35. Transfer
to health
facilities
1
2
3
Capitation + Fee for service
Fee for service
Fee for service + Differential
prices
Evolution in the transfer scheme
 Generate confidence
 Make resources flow rapidly
to health facilities
 Wait for billing systems to be
developed
 To better promote quality
1st year of
implementation
San Juan Province: USD32 prenatal control before 13th week
USD18 prenatal control after 13th week

36. Pay for Performance in High Complexity
Surgeries
FEDERAL NETWORK
Key Aspects
• More coordination
• Interprovincial agreements
• Performance based contracting
• Pay for performance
• Mandatoryinvestment planning
Diagnosis & Referral Centers (42)
Treating Centers(17)
Referral Coordination Center(1)
+

37. Fee for service based on
the report of quality
attributes
Performance based hiring
for high complexity
providers
Capitation payments to
provincesbased on quality
goals
Measuring expectationsand
perception of care
1. According to different levels of health
service utilization
2. According to different levels of
performance of the health providers
PERCEIVED
QUALITY
TECHNICAL
QUALITY
Fee for service + external
qualityevaluation and
training
Promoting and Evaluating Quality of Care
Pay for
Performance
Beneficiary satisfaction
8 over 10 women are
satisfied with Plan Nacer
coverage

38. Health Team Training
E-learning
Courses
Programa SUMAR
Scholarships
15 coursesare free of charge
and self-administered
22,900 users 240 members
Managementand Evaluationof
Programsand Health Services
Training Program

39. Final thoughts

40. MONETARYINCENTIVES
MANAGEMENT
TOOLS
EMPOWERMENT
LEADERSHIP
Provinces andFacilities:
Transfers (+)
Debits and Fines (-)
Facility staff:
Performance basedbonus
(only 8 provincies)
Increased Autonomy
Betterwork
environment
Traning opportunities
Perfomance indicators
Auditing
Strategic planning
Long-term goals
Reliability
Flexibility
Bench-learning
How do Plan Nacer and Programa SUMAR
encourage behavioral changes?
Building a New Culture

41. Average 1.2%
*
* Figures include the amount of transfers for Programa SUMAR for the last four months of the year.
How much did Program transfers amount to in 2012
out of provincial health expenditure?

42. Contribution to the reduction in mortality rates
2005 - 2012
 22%
 30%
IMR
MMR
(per 1,000 nb)
(per 10,000 nb)
2005: 3.9
2012: 3.5
14.3
11.1
18.7
13.0
 10%

43. 1. Strenghthened national and provincial leadership
2. Succesfull reorientation of the health care and
management model
3. The first building block is a multidisplinary team
4. RBF can help to create organizations based on 5
excellence principles like:
- Results Orientation
- Citizen Focus
- Management by processes and facts
- People developmentand involvement.
- Continuouslearning, innovation and improvement
5. RBF as the core of a cultural transformation process
5 Final Thoughts

44. ¿What are we doing to
institutionalize Plan Nacer?
1. New management skills
2. More integration with Provinces,
Social Security and social policies.
3. Sustaining the innovation environment

45. Committed People

46. WELCOME TO ARGENTINA

47. www.msal.gov.ar/sumar/
www.facebook.com/ProgramaSumar

48. Plan Nacer ‘s
Results

49. 57,1%
64,5%
Embarazadas sin cobertura
formal de salud
Embarazadas del Plan NACER
Percentage of pregnant women enrolled before
week 20th of pregnancy
13% 4.4
5.1
Embarazadas sin cobertura
formal en salud
Embarazadas del Plan
NACER
Number of average prenatal checkups per
pregnant woman
16%
Earlier detection of
pregnancy
2 Provinces 2006-2009
More checkups
6 provincesin the North 2004-2008
9.1%
7.0%
Niños de madres sin cobertura formal en
salud
Niños de madres del Plan NACER
Percentage of children with low birth weight (<2500 gr)
23%
Pregnant women without
formal health coverage
Pregnant women with Plan
Nacer
Pregnant women without
formal health coverage
Pregnant women with
Plan Nacer
Children born to pregnant women without
formal health coverage
Children born to pregnant women with
Plan Nacer
Impact Evaluation
Reduction of 23%
in the risk of low
birth weight

50. How did it reduce neonatal mortality?
 Better prenatal care - Preventing
LBW (54%)
 Better care for LBW babies (46%)
74%9.50%
2.47%
NMRNo Benficiaries NMRBeneficiaries
Impact on Neonatal Mortality
Beneficiary
satisfaction
8 over 10 women are
satisfied with Plan
Nacer ´s coverage
Reduction of 25% in C-
sections (in beneficiary
mothers)
Reduction in the risk of
neonatal death
An increase of 48 % in
the application of
tetanus vaccination for
beneficiary pregnant
women
Impact Evaluation