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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
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