Improving Health Care for Rural Mothers and Children in Panama
A Results Based Financing Approach in Panama’s Health Sector.
January 31, 2014
Panama’s key health sector challenge is to address inequitable health access for the poor while consolidating and scaling up existing incentives for the health system to improve the efficiency, effectiveness, and long-run sustainability. Individuals from rural poor and indigenous households experience lower health outcomes compared to other areas in Panama. Mortality rates for children under five years old in Bocas del Toro and the indigenous areas (comarcas) Ngobe Bugle and Kuna Yala are respectively 2.4, 1.9, and 1.6 times higher than the national average of 19.9 deaths per 1,000 live births.
In 2003, in an effort to address the issue of inequitable health access for the poor, Panama’s Ministry of Health (MOH) implemented an expanded national program to extend coverage of primary health care services (Estrategia de Extension de Cobertura – EEC) and increase access to health services. The expanded program included the delivery of the Integrated Package of Health Care Services (PAISS, for its Spanish acronym) to remote rural and indigenous areas using capitation payments that created financial incentives for providers to achieve better results, a results-based financing (RBF) approach. After five years of the PAISS experience, the MOH took the EEC to the next level by launching the Health Protection for Vulnerable Populations (PSPV) program which provided health services to the rural poor through mobile health teams. The PSPV was launched using an RBF approach supported through the Bank project which financed the capitation payments to the health regions which served as a financial incentive to increase coverage and improve performance.
The Bank embarked on an approach to help Panama address the inequitable health access for the poor through the design, launch, and implementation of the “Health Equity and Performance Improvement” (HEPI) Project in partnership with the MOH. Through the project a pair of complementary innovations were rolled out which included mobile health teams and the use of a results-based financing (RBF) approach. By financing mobile health teams, the project took away the burden of seeking health care from the rural poor and instead directly brought health care to the community. With regard to the RBF approach, the project financed capitation payments which consist of three tranche payments to networks of health facilities which enter into contracts with the MOH to provide services to the selected communities, through the mobile health teams. The first tranche is paid every two months (at the end of each health round) and can be a maximum of 65 percent of the per capita amount and is based on the achievement of target coverage levels. The second tranche, paid every 4 months, is for a maximum of 30 percent of the per capita amount and is paid according to achieving performance targets for health service provision among the registered beneficiary population. The third tranche is paid annually and accounts for 5 percent of the per capita amount based on a social audit which includes a survey among beneficiaries who received services to measure satisfaction levels.
At its start, the project suffered long delays in implementation due to factors outside the executing agency’s control. To provide a concrete solution to this problem, a first set of changes was made to the project in June 2012 which included: (i) extending the project closing date by 18 months to allow the project to have a full 5 years of provision of health and nutrition services through the mobile teams, (ii) introducing more flexibility in the percentage distribution of counterpart and loan funds for disbursements (the pari passu) across all project components, (iii) simplifying the disbursement conditions to allow capitation payments to be made against the certification of the beneficiary roster conducted by the external audit firm and not require a second certification which caused delays, and (iv) revising the targets of some indicators in light of baseline data. A second change was made to the project in October 2013 to respond to a significant reduction in funds assigned to the project for external and counterpart funds. This second change reallocated funds across categories to allow the project to maintain its current pace of implementation and finance the project’s central activity, the capitation payment for the provision of the basic package of health services to the target population of under-served rural communities.
By mid-2013, 203,220 beneficiaries from 47 underserved rural populations across 10 health regions gained access by way of mobile health units to a basic health package to improve mother and child health care, through financial support from The International Bank for Reconstruction and Development (IBRD).
By the end of 2012:
- 75% of pregnant women completed at least three pre-natal controls by the third trimester (target: 60%)
- 89% of children (under one year old) having a complete vaccination scheme for their age (target: 80%)
- 93% of live births attended by skilled personnel (target: 55%)
- 82% of children (under one year old) with four or more controls for growth and development (target: 67%)
- Communities visited—achieved 97% (target: 85%)
- Population groups protected—achieved 100% (target: 80%)
- Protected population effectively treated—achieved 57% (target: 50%)
- Protected children (under 24 month’s old) treated—achieved 86% (target: 80%)
- Days of service/care—achieved 100% (target: 100%)
- 75% of pregnant women with at least three prenatal check-ups (at least one per trimester) by the end of the third trimester (target: 60%)
- 70% of pregnant women registered out of estimated total (target: 98%)
- 95% of pregnant women with second dose or booster of TT or TD (tetanus-diphtheria vaccination according to regulations) (target: 88%)
- 93% of births attended by trained staff (target: 80%)
- 40% of women 20 years or older having Pap smears (target: 44%)
- 82% of children (under one year old) who have had four or more growth and development check-ups (target: 74%)
- 89% of children (under one year old) with a complete vaccination record (target: 80%)
- 73% of children (under four year’s old) with at least two growth and development check–ups during the period (target: 67%)
- 72% of children (from one to four year’s old) with a complete vaccination record (target: 76%)
- 1.9% of symptomatic respiratory diseases recorded out of estimated total (target: 0.9%)
Bank Group Contribution
The Bank’s intervention consisted of the Panama Health Equity and Performance Improvement Project – US$40 million – IBRD. The project was approved on August 5, 2008 became effective on December 8, 2008 and will close on December 31, 2014.
The World Bank works closely with the Ministry of Health’s Financial and Administrative Management Unit (UGSAF, for its Spanish acronym) who maintains fluid communication with the Ministry of Health and Ministry of Economics and Finance. In addition, the project is implemented in a coordinated manner with the Inter-American Development Bank which finances the network of fixed units for health care and covers the indigenous communities health needs while the Bank finances the mobile units for underserved rural areas.
Through HEPI implementation support missions, by virtue of the Bank’s comparative advantage, it provides technical expertise to review the implementation of the RBF scheme and makes suggestions to strengthen the processes involved.
In light of the fact that the HEPI project closes in December 2014, the Bank continues to maintain an open dialogue with the Government of Panama and to work in close coordination with the IDB. Once the HEPI project closes, the beneficiary groups of the project would be absorbed by an IDB-supported Health Reform Project. Continued Bank engagement in Panama’s health sector would be in the form of analytical work to produce and share knowledge with the Government to better understand the use and distribution of financial and human resources in the health sector.
Hilaria Palacios is a mother of five children and is four months’ pregnant with her sixth. Before, it was very difficult for Hilaria to access health services, due to the distance she had to travel to reach the fixed health unit, which involved walking long distances or prohibitive transport costs. Thanks to the visits to her community by the mobile team of health professionals, access to health services is brought to Hilaria by the mobile team. The mobile teams are comprised of a six-person team, including a doctor, nurse, nurse technician, nutritionist, health sanitation and environment specialist, and a driver. Thanks to this approach, Hilaria now has access to quality, basic health services, every month during her pregnancy.
Hilaria Palacios, project beneficiary commenting on the difficulty accessing care prior to the mobile health teams. “I had to walk or take a boat to receive check-ups. It was very difficult.” Today, Hilaria receives care from the mobile health teams. “Here, I receive monthly check-ups from the Doctor."