Plan Nacer and Programa SUMAR

Moving Forward towards Effective

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

Context Nation Stewardship role

Primarily responsible

for the provision of

health care Provinces

Federal Organization

ARGENTINA

after the worst crisis

2002

Half the population without social or private health insurance (48%)

65% of children uninsured

IMR 16.8 (per 1000) and 22 (per 1000) in

the Nothern Region

Gaps in access to health services

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?

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Plan Nacer ´s

goals and target

population

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

health services

Final Objetives

Improve the health status of population

Increase

satisfaction

10 Million Eligible

Population without formal

insurance

Gradual Implementation

2005 - Phase 1:

PLAN NACER

pregnant women

and children 0-6

2012 - Phase 2:

PROGRAMA SUMAR

women 0-64

and men 0-19

2016 - Phase 3:

women 0-64

and men 0-64

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

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Plan Nacer ´s

Pay for Perfomance

Mechanisms

Results-Based Financing

NATION

Sets a per

capita value

USD2.5

PROVINCE

Health performance

indicators - Tracers

(every four months)

Enrollment

(monthly payment)

Capitation payment based on performance

Provincial

Health Insurance

Umbrella Agreement

External and internal verification

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 viral vaccine

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

Results-Based Financing

PROVINCE HEALTH PROVIDER

Fee for

Service

(monthly payment) Provincial

Health Insurance

Performance Agreement

External and internal verification

Autonomy in the

use of funds The Nation defines

the list of authorized

health services and

each Province sets

the prices.

The facility is

assigned a bank

account where 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

months to

bill the

services

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

Capitation payment based on performance

USE OF FUNDS •Staff Incentives •Staff hiring and training •Supplies •Investment •Maintenance

BALANCE

Virtuous cycle promoted by the Program

1. Health care is provided to the

population

2. Health professionals

complete the medical records

3. Administrative staff

bill the health services.

Each province develops

its own IT system.

6. Additional resources

for health providers

4. Verification and Payment

• Tracer measurement

7. Improvements in health care

5. Ex post Verification

7 steps

Gradual Scale-up

Plan Nacer´s Health Care Coverage

Prevention and

Promotion

Congenital Heart

disease Surgery

Treatment of

Prevailing

Pathologies

High Complexity

Perinatal Care

Health Interventions

for children,

adolescents and

women

100 health services

400 health services

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

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

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

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 incentive scheme

promotes and improves the

quality of clinical records and

timely reporting

Availalable Clinical Records

2005: 2.8 over 10

2012: 9 over 10

How do health facilities invest their

recourses?

Autonomy

Total Country – Accumulated values to October 2013

Maintenance

Total Country- Accumulated Values October 2013

8 Provinces with Staff

incentives 16 Provinces without

Staff incentives

Autonomy

The National Program

establishes that staff

incentives must

represent < 50% total

funds

.

In the province of Buenos Aires,

staff incentives are capped at 25%

at municipality level

Maintenance

Maintenance

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

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.

What do health teams value?

1. Improved organization

2. Improved professional practice 3. Increase in coverage 4. Improved workplaces TESTIMONIOS PN - SUMAR 2013 subt.wmv

67,2 Index

Satisfaction Northern

Region

Increase in Health Team Motivation

7370 Facilities

participating

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Plan Nacer ´s

Verification Scheme

Concurrent All year in the field

Bimonthlyreports

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 and misreporting in: 1. Roster information 2. Billing and payments to health facilities 3. Tracers

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.

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%)

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Ongoing learning,

Innovation and

improvement

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

Impact of changes in the retribution scheme

Plan Nacer Tracers

33%

All or nothing Continuous

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

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Results-Based Financing

New Performance Indicators Used to evaluate provincial systems

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

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

Pay for Performance in High Complexity

Surgeries

FEDERAL NETWORK

Key Aspects

• More coordination

• Interprovincial agreements

• Performance based contracting

• Pay for performance

• Mandatory investment planning

Diagnosis & Referral Centers (42)

Treating Centers (17)

Referral Coordination Center (1)

+

Fee for service based on

the report of quality

attributes

Performance based hiring

for high complexity

providers

Capitation payments to

provinces based on quality

goals Measuring expectations and

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

quality evaluation and

training

Promoting and Evaluating Quality of Care

Pay for

Performance

Beneficiary satisfaction

8 over 10 women are

satisfied with Plan Nacer

coverage

Health Team Training

E-learning Courses

Programa SUMAR Scholarships

15 courses are free of charge and self-administered

22,900 users 240 members

Management and Evaluation of Programs and Health Services

Training Program

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Final thoughts

MONETARY INCENTIVES

MANAGEMENT TOOLS

EMPOWERMENT LEADERSHIP

Provinces and Facilities: Transfers (+)

Debits and Fines (-)

Facility staff: Performance based bonus

(only 8 provincies)

Increased Autonomy

Better work

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

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?

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%

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 development and involvement. - Continuous learning, innovation and improvement 5. RBF as the core of a cultural transformation process

5 Final Thoughts

¿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

Committed People

WELCOME TO ARGENTINA

www.msal.gov.ar/sumar/

www.facebook.com/ProgramaSumar

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Plan Nacer ‘s

Results

57,1%

64,5%

Embarazadas sin coberturaformal de salud

Embarazadas del Plan NACER

Percentage of pregnant women enrolled before week 20th of pregnancy

13% 4.4

5.1

Embarazadas sin coberturaformal en salud

Embarazadas del PlanNACER

Number of average prenatal checkups per pregnant woman

16%

Earlier detection of pregnancy

2 Provinces 2006-2009

More checkups 6 provinces in the North 2004-2008

9.1%

7.0%

Niños de madres sin cobertura formal ensalud

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

How did it reduce neonatal mortality?

Better prenatal care - Preventing

LBW (54%)

Better care for LBW babies (46%)

74% 9.50%

2.47%

NMR No Benficiaries NMR Beneficiaries

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