Plan Sumar Program (supported by the Bank with a US$400m. investment project) was rolled out on October 17 and builds on 7 years of results-based financing experience from a maternal and child health initiative, Plan Nacer. Plan Nacer is a targeted public health insurance program eligible for uninsured women who were pregnant or had recently given birth (up to 45 days post-delivery), and children under 6 years of age. The program uses results-based payments at the provincial and health facility level to increase enrollment in the program and provide critical peri-natal and childhood services such as immunization. The Plan includes a specific package of services which enrolled individuals receive free of charge. Provinces are paid a capitation fee for enrolling qualified beneficiaries, and health facilities receive fee-for-service payments for providing services. Health facilities have significant autonomy in deciding how the incentive money will be spent and can use some of it for salary bonuses and some of it for improving delivery of services, for example, supplies, medicines, small equipment, or maintenance. Plan Sumar uses the same RBF payment model but expands coverage to also include children age 6-19, and women age 20-64. It will also expand the package of services included and add longer-term participation goals.  To be considered a Plan Sumar beneficiary, in addition to be enrolled in the program, the beneficiary must receive a health intervention billed and authorized by the program in a given period of time. In addition to the umbrella agreements and annual performance agreements, Plan Sumar requires that the provinces comply with a minimum set of population coverage, institutional goals and service targets related to Plan Nacer’s implementation.

Although the official evaluation of Plan Nacer will be completed in the spring, it has been considered a success by the government of Argentina and the World Bank due to substantial institutional changes aimed at improving the efficiency of the delivery of health care services from Provincial Health Ministries in the context of a decentralized health system. Since its beginning, Plan Nacer has provided health coverage to more than 4.7 million pregnant women and children, delivering around 37 million health services. Today, the program has reached 92.4 % of the eligible population. Although not solely attributable to Plan Nacer, health indicators have improved since its inception. The infant mortality rate decreased from 14.4 in 2004 to 11.9 in 2011[1]. Preliminary evaluations of Plan Nacer have shown increases in average birth weight, lowered probability of very low birth weight babies, improved Apgar scores, and a reduction in early neonatal mortality. As Plan Nacer transforms into Plan Sumar, the expanded number of services and larger eligible population will continue to put the focus on results and strengthen the public health system.

Rafael Cortez of the World Bank said that the key to Plan Nacer’s success and Plan Sumar’s development is the strong commitment and involvement of the Argentine government. The government of Argentina believes that the results-based financing model is a strong tool to affect system-wide changes, and views the World Bank as a critical partner in helping them achieve their objectives. Cortez was particularly impressed with the way in which the Argentine government continuously put new challenges on the table and worked to improve and evolve the program. He also stated that strength of the program is a robust monitoring and evaluation component that uses an external auditor that allows the central government to more openly discuss results with the provincial governments.

When asked how Plan Nacer has changed the health system, Cortez noted that Plan Nacer has helped implement a stronger data culture to make decisions based on evidence, improving both the system of collection and the use of data. For example, now the government is able to specifically identify the beneficiaries and record their health information, and when eligible children visit a health facility for curative care, they can be enrolled and the entire package of services can be offered. It has affected the dynamics of the health facility such that results are demanded following the results has become a quality improvement process.

Cortez wants to caution others who are thinking about implementing large scale RBF programs such as Plan Sumar in a country: Plan Sumar wasn’t built overnight. It is the result of over 7 years of experience with a previous program, Plan Nacer, learning, evolving, and building a system that uses results-based financing as a tool to improve the health system, increase participation, increase quality, get results, and provide insurance. In addition, there was a strong political commitment from the government to make thoughtful changes to improve the efficiency and effectiveness of a decentralized and complex health system. He sees RBF as an excellent mechanism to strengthen universal health coverage initiatives ensuring people receive affordable and quality health care.  However he cautions that there are often demands from the field for immediate results, and therefore donors, officials or managers can get impatient and overly optimistic about the potential results from a RBF investment. In addition, he warns against designing RBF projects beyond the implementation capacity of the country and reminds us not to expect large improvements quickly.  Cortez points out that to move from pilots to a large scale RBF investment is also a challenge for the implementers and the Bank. Despite the fact that some health service outputs and outcomes can be observed in the short term, at least a ten year horizon may be required for any results-based financing initiative to show concrete, long–term results at the institutional level in a large scale investment. He suggests starting with a few process indicators that can show that progress is being made. As the program evolves it can go from relatively simple objectives (e.g. enrollment), to more sophisticated ones (e.g. effective enrollment—requiring continued use of services to receive payment).

As Plan Nacer finishes at the end of the year, Plan Sumar builds on the successes and lessons learned to reach even more people and cover more services by keeping the focus on results and strengthening the public health system.

[1] National Ministry of Health, 2012.

Resource Information

Author/s: Anna Heard
Countries: Argentina
Date of Publication: October 2012

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