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BRIEF

Argentina’s Plan Nacer: Delivering Results for Mothers and Their Children

September 18, 2013

Also available in Spanish

September 19, 2013 --- The results are in and they are decisive: a program combining results-based financing (RBF) approaches with strong stewardship from the Ministry of Health, technical assistance and investments on service delivery can help improve maternal and child health outcomes and use of health services.

The impact evaluation of Plan Nacer – Phase I, Argentina’s health coverage program for uninsured pregnant women and children under the age of six, shows  that the use and the quality of prenatal services is up, resulting in reduced incidence of low birth weight (less than 2500 grams) and lower in-hospital neonatal mortality.[1]

Plan Nacer

The 2001 economic crisis plunged more than half of Argentina’s population into poverty and resulted in high unemployment.[2] Many Argentines lost their health coverage, and turned to the public health system for care. The increased demand strained the system’s capacity to deliver services, and basic health indicators deteriorated. Between 2000 and 2002, Argentina’s infant mortality rate increased from 16.6 to 16.8 per 1,000, and in the country’s poorer northeastern and northwestern provinces, infant mortality was as high as 25 per 1,000.[3] As a result, the Government of Argentina developed Plan Nacer to both reduce infant mortality by increasing access to health care to uninsured pregnant women and children under age six; and to improve the efficiency and quality of the public health system by introducing changes in the incentive framework [4].

Plan Nacer’s RBF mechanisms created two levels of incentives: one between the national and provincial governments, and the other between the provincial governments and health facilities. Provincial governments received capitation payments from the National Ministry of Health based on the number of beneficiaries enrolled in Plan Nacer, and on the achievement of specified health indicator targets. Health facilities received fee-for-service payments from the provincial government according to the number and quality of services they provided.[5] These health facilities benefitted from substantial autonomy in deciding how to use the RBF incentives. Some paid bonuses to health workers, while others reinvested in the facility to make improvements in infrastructure and service delivery.[6]

The Government launched phase I of Plan Nacer in nine of Argentina’s poorest provinces in 2005, and brought the program to the 14 remaining provinces and the Autonomous City of Buenos Aries in phase II in 2007. Plan Nacer has since provided 4.7 million pregnant women and children with health coverage, and has facilitated the delivery of 37 million maternal and child health services.

Impact Evaluation

The impact evaluation of Plan Nacer has been supported by the World Bank Group’s Health Results Innovation Trust Fund (HRITF) and the Spanish Impact Evaluation Fund (SIEF). 

The impact evaluation provided a framework for a broader research agenda designed to examine how Plan Nacer’s mechanisms worked and to what extend its results were achieved.

Data and Method

The research team, led by Professor Paul Gertler of the University of California Berkeley, used a unique dataset based on birth and medical records combined with administrative data to estimate the causal impact of Plan Nacer on specific birth outcomes for the period 2004-2008 in six of the program’s nine initial provinces.

Specifically, the team investigated two questions:

(i) What was the impact of incorporating clinics into Plan Nacer on the health outcomes and service utilization of pregnant women and babies that used those clinics, regardless of whether they themselves were Plan beneficiaries?

(ii) What was the impact of incorporating clinics into Plan Nacer on the health outcomes and service utilization of Plan beneficiaries that used those clinics?

Results

The results show that Plan Nacer had large positive effects on birth outcomes. Specifically, the research team estimates that incorporating clinics into Plan Nacer reduced the probability of low birth weight by 9% for users of those clinics, and by 23% for Plan Nacer beneficiaries. 

Birth records from larger maternity wards also show that Plan Nacer reduced the probability of in-hospital neonatal death by 22% for users of Plan Nacer clinics, and by 74 % for Plan Nacer beneficiaries. Approximately half of the reduction in deaths is attributed to better prenatal care that prevented low birth weight, while the other half is the result of better post-natal care.

The program also increased the use and quality of prenatal care services as measured by the number of prenatal care visits and the probability of pregnant women receiving a tetanus vaccine.

Next Steps

Next steps in the evaluation agenda of Plan Nacer – Phase I Provinces include the use of Health Facility and Household Survey Data to assess impact on quality of care, health services utilization and health outcomes.

Beyond Plan Nacer

Lessons from Plan Nacer’s results are particularly valuable as the government of Argentina implements Program SUMAR. [7] This new Program uses Plan Nacer’s RBF mechanisms, while extending health coverage to uninsured children and adolescents under the age of 19 and to uninsured women between the ages of 20 and 64; it also continues to provide coverage for uninsured pregnant women. 

Between 2012 and 2015, Program SUMAR is expected to cover 5.7 million children and adolescents, and 3.8 million women 20- 64 years, including 230,000 pregnant women.

The results from Plan Nacer’s impact evaluation are among the first to emerge from HRITF’s portfolio of results-based impact evaluations, and they make an exciting contribution to the evidence base on the successful implementation of results-based mechanisms. They also provide policy makers and global health practitioners in low- and middle-income countries with the evidence that performance-based financing can improve the health outcomes of pregnant women and children, and their use of services, while boosting the performance of health systems.

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[1] Gertler, P. Giovagnoli,P, and Martinez, S. (in preparation for publication). Rewarding Performance To Enable a Healthy Start: The Impact of Plan Nacer on Birth Outcomes of Babies Born into Poverty. The World Bank.

[2] Fiszbein, A., Giovagnoli, P.I., and Adúrez, I. 2002. Argentina’s Crisis and its Impact on Household Welfare. Working Paper 1/02. The World Bank.

[3] Cortez, R. and Romero, D. 2013. Increasing Utilization of Health Care Services Among the Uninsured Population: the Plan Nacer Program. Universal Health Coverage Study Series. The World Bank

[4] Measham, A. and Cortez, R. Argentina: Plan Nacer Fact Sheet. The World Bank. www.rbfhealth.org

[5] Fridman, V. et al 2009. Argentina: Provincial Maternal and Child Health Insurance - a Results-based Financing Project at Work. En Breve. The World Bank.

[6] Heard, A. 2012. Argentina Builds on Plan Nacer to Evolve into Plan Sumar. www.RBFhealth.org

[7] Ministerio de Salud Argentina 2013. El programa SUMAR es más salud pública. www.msal.gov.ar