Argentina’s Plan Nacer: Rewarding Performance to Enable a

Healthy Start to Life

Paul Gertler Paula Giovagnoli

Sebastian Martinez

March 2014 Buenos Aires, Argentina

Today

• What is Plan Nacer

– Origins and objectives

– Policy Mechanims

– Comparison to other models

• Evaluation

– Prenatal Care & Birth Outcomes

– Evidence from 7 northern Provinces

Priority: Improve Birth Outcomes of

Babies Born into Poverty…

• Low Birth Weight

Associated with poor

– Health

– Education

– Earnings

• Uninsured & little access to quality care

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

Incentivzed Financing Scheme

NATIONAL

GOVERNMENT PROVINCIAL

GOVERNMENTS

Health outcomes

Enrollment

Pay for

performance

HEALTH

FACILITIES

Fee for

service

Umbrella Agreements

EXTERNAL AUDIT

Provincial Health Insurance

Performance Agreements

EXTERNAL AUDIT

Facility

decides on

use of funds

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

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

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

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

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)

Provincial Implementation Enroll both facilities & beneficiaries

• Facility enrollment over time

0

.2

.4

.6

.8

1

Cum

ula

tive P

roba

bility

2004q3 2005q3 2006q3 2007q3 2008q3Quarter

c.d.f. Normal c.d.f.

Beneficiary Enrollment

Children Mothers

0

100,000

200,000

300,000

400,000

500,000

600,000

2004 2005 2006 2007 20080

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

Today….

• Evaluation:

– Questions

– Data

– Methods

– Results

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

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

Plan Nacer Increases Prenatal Care Use

4.4

5.9

3.6

0

1

2

3

4

5

6

7

Number of Prenatal Care 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 Initiating Prenatal Care Before 20 weeks

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

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

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 Mortality of LBW Babies 0.0095

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

Overall NeoNatal Mortality

Series1

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

Very Cost - Effectiveness

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

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

Many Thanks to All

Contact information:

Paul Gertler

Li Ka Shing Professor of Economics

UC Berkeley

Gertler@haas.berkeley.edu