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Long run effects of temporary incentives on medical care productivity in Argentina

A presentation by Pablo Celhay, Paul Gertler, Paula Giovagnoli and Christel Vermeersch, delivered at the RBF Health Seminar, On the Road to Effective Universal Health Coverage: What’s New in Argentina’s Use of Performance Incentives? on June 11, 2015.

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Long run effects of temporary incentives on medical care productivity in Argentina

  1. 1. J U N E 1 1 , 2 0 1 5 P A B L O C E L H A Y P A U L G E R T L E R P A U L A G I O V A G N O L I C H R I S T E L V E R M E E R S C H Long Run Effects of Temporary Incentives on Medical Care Productivity
  2. 2. TEMPORARY INCENTIVES HAD A LONG - RUN IMPACT ON MEDICAL CARE PRODUCTIVITY TEMPORARY INCENTIVES HELPED OVERCOME THE INITIAL COST OF IMPROVING MEDICAL CARE ROUTINES Main findings
  3. 3. Routines in medical care  Medical care is a complex technology  Coordination of team activities is key  Routines = “Established rules”, “standard operating procedures” that become habits
  4. 4. Institutions have a hard time changing their routines. .. It takes effort .. It takes time .. It might be costly
  5. 5. Medical care routines can be suboptimal E.g.: Adherence to clinical practice guidelines (best- practice) is low. 18% 24% 45% 46% 50% 60% 67% 75% 81% 84% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% India - Diahrrea Tanzania - Malaria Rwanda - Prenatal Care Indonesia - Tuberculosis USA - Preventive Care USA - Chronic Conditions Netherlands - Family Mexico - Prenatal Care UK - Diabetes UK - Asthma Adherence to CPG Source: Authors’ elaboration based on Schuster et al. (1998); Grol (2001); Campbell et al. (2007); Das and Gertler (2007); and Gertler and Vermeersch (2012).
  6. 6. Role of incentives – causal chain  Initial/Upfront cost inhibits change of routines  Financial incentives may help overcome this initial cost  Once the institution adopts new routines, it will continue them as long as recurrent costs are covered.
  7. 7. The Misiones experiment Misiones Province
  8. 8. The Misiones experiment  Aim: Increase the probability that 1st prenatal visits take place in first trimester  In primary care setting  Intervention: Temporary (8 months) increase in fees 40 120 40 40 0 20 40 60 80 100 120 140 Pre & post periods Intervention period Fee-for-service payment for 1st prenatal visit before week 13 Treatment Control +200% A r g . P e s o s
  9. 9. The Misiones experiment  Identification strategy:  Randomized assignment of 37 primary care clinics to treatment and control  Assignment not fully respected (but close enough)  use IV estimator Treated Not treated Assigned to treatment 14 4 Assigned to control 1 18
  10. 10. Timeline Jan 2009 May 2010 Dec 2010 Mar 2012 Dec 2012 Pre-intervention Intervention Post intervention I Post intervention II
  11. 11. Data  Clinic records  services delivered  Registry of Plan Nacer beneficiaries  beneficiary status of the mother  Hospital medical records  birth outcomes link using the mother’s national identity number
  12. 12. Results
  13. 13. Weeks pregnant at first prenatal visit PRE POST -1.47
  14. 14. Proportion of mothers with prenatal visit before week 13 PRE POST +0.11
  15. 15. Density of birth weight Pre-intervention Intervention We do not find an impact on birth weight.
  16. 16. C H A N G E S I N R O U T I N E S E V I D E N C E F R O M I N - D E P T H I N T E R V I E W S Mechanisms
  17. 17. What did treatment clinics do?  Change in assignment of incentives to personnel  Conditioned on number of women brought in  Change in routines to improve efficiency of outreach by community health workers  Offer pregnancy tests to mothers when picking up milk for their children  Visit adolescents when parents aren’t home  Visit women who abandoned birth control pills  Organize the Ob/Gyn schedule to ensure predictability of service
  18. 18. Increase in maternal-child “hits” due to outreach  Treatment and comparison clinics equally paid for outreach activities that result in actual maternal-child service at the clinic
  19. 19. Why no impact on birth outcomes?  Hypothesis: Impact of early prenatal care is uneven in the population  Need to be able to reach very high risk women  Impacts are washed out in a population average
  20. 20. I n c e n t i v e s i n c r e a s e d i n i t i a t i o n o f p r e n a t a l c a r e b e f o r e w e e k 1 3 b y 3 5 % . E f f e c t p e r s i s t e d f o r a t l e a s t o n e y e a r a f t e r t h e i n c e n t i v e s e n d e d . T e m p o r a r y i n c e n t i v e s h e l p p r o v i d e r s t o o v e r c o m e i n e r t i a a n d c h a n g e c l i n i c a l p r a c t i c e r o u t i n e s . N e e d t o t a i l o r i n c e n t i v e s t o t a r g e t h i g h - r i s k p o p u l a t i o n s . Conclusions
  21. 21. Martin Sabignoso, National Coordinator of Plan Nacer and Humberto Silva, National Head of Strategic Planning of Plan Nacer led the development and implementation of the experiment. Luis Lopez Torres and Bettina Petrella from the Misiones Office of Plan Nacer oversaw the implementation of the pilot facilitated access to provincial data, supported the authors in interpreting datasets and the provincial legal framework and in carrying out the in-depth interviews. Fernando Bazán Torres, Ramiro Florez Cruz, Santiago Garriga, Alfredo Palacios, Rafael Ramirez, Silvestre Rios Centeno, and Adam Ross provided excellent assistance and project management support. Alvaro Ocariz, Javier Minsky and the staff of the Information Technology unit at UEC provided valuable support in identifying sources of data. Sebastian Martinez, Luis Perez Campoy, Vanina Camporeale and Daniela Romero contributed to the initial design of the pilot. The Health Results Innovation Trust Fund (HRITF) and the Strategic Impact Evaluation Fund (SIEF) of the World Bank generously funded the evaluation. The opinions in the paper are of the authors alone and do not necessarily represent the opinions of the funder or their affiliated institutions. Acknowledgements

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