annual results and impact evaluation workshop for rbf - day three - argentina's plan sumar
Post on 17-Jul-2015
58 Views
Preview:
TRANSCRIPT
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?
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
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
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%)
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
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
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
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
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
top related