gertler cgd plan nacer presentation · argentina’s plan nacer • improve maternal and child...
TRANSCRIPT
Argen&na’s Plan Nacer: Enabling a Healthy Start for Babies Born into Poverty
Paul Gertler Paula Giovagnoli
Sebas9an Mar9nez
September 18, 2013 Center for Global Development, Washington DC
Today….
• Context:
Why is Plan Nacer Unique?
• Evalua9on
Priority: Improve Birth Outcomes of Babies Born into Poverty…
• Low Birth Weight
• Associated with poor – Health – Cognitive development – Education – Earnings
• Uninsured & little access to quality care
Argentina’s Plan Nacer
• Improve maternal and child health – Access to quality care
• Mechanisms – Target uninsured users of public facilities – More money to providers – Incentives
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
Health facility decides on the use of funds
Plan Nacer Similar to Other Programs
• Examples – Medicaid in United States – Seguro Popular in Mexico
• Local governments responsible for care of uninsured (poor)
– Co-‐financed with na9onal government – Capita9on payment per enrollee
Plan Nacer Capita9on More Sophis9cated
• Payment Per Beneficiary – Medicaid (100%) – Seguro Popular (100%) – Plan Nacer (60%)
• Plan Nacer Adds Performance Incen9ves – Health outcomes – U9liza9on and quality – Up to 40% of max payment
Innova9ve Features
• Na9on to Province Capita9on – Performance Incen9ves & Health Outcomes
• Few others use health outcomes incen9ves for local governments – Indonesia: villages incen9ves payments for nutri9on outcomes
– India: village incen9ves for open defeca9on free
• Many use FFS payments to providers
Today…. • Context:
• Evalua9on: – Ques9ons – Data – Methods – Results
Birth Cer9ficate Data
• Universe in public hospitals – 6 northern Provinces – 2004-‐08
• Very large sample sizes
• Important rare outcomes – Low Birth weight – Neonatal mortality
Eligible and Beneficiary Popula9on 0
.2.4
.6.8
1
2004 2005 2006 2007 2008Año de parto
Beneficiary Eligible
Evalua9on Objec9ves:
Impact of a clinic enrolling in Plan Nacer on outcomes of..
• all pa9ents regardless beneficiary status – (Intent to Treat):
• beneficiary pa9ens – (Treatment on The Treated):
• non-‐beneficiaries pa9ents – (Spillover)
Methods
• ITT: Difference in Differences – Phased clinic enrollment over 9me – Clinic and province-‐9me fixed effects – Balance and pre-‐interven9on trend tests
• TOT & Spillover: IV Difference in Differences – Clinic enrolled – Time enrolled – Demographics*enrollment
Timing of Clinic Enrollment into Plan Nacer
0
.2
.4
.6
.8
1
Cum
ulat
ive
Prob
abilit
y
2004q3 2005q3 2006q3 2007q3 2008q3Quarter
c.d.f. Normal c.d.f.
Mean Birth Weight by Beneficiary Status Over Time 32
0032
2532
5032
7533
0033
25
Birth
wei
ght (
gram
s)
2004 2005 2006 2007 2008
Beneficiary Non-Beneficiary
Birth Weight Event History Analysis Non-‐Beneficiary (Red) over 9me
How Plan Reduced Neonatal Mortality
• Neonatal mortality all from LBW babies
• Lower by – Preven9ng LBW – Befer care for LBW babies
• Find – 54% of reduc9on from preven9ng LBW – 46% from befer care for LBW babies
Lessons • Plan Nacer innova9ve
• Very effec9ve – More & befer prenatal care – Improved birth outcomes – Lower neonatal mortality
• Maybe a good model for others to consider
• Birth/Medical records valuable for evalua9on
Limita9ons
• Only 6 Provinces • Limited data on Mechanisms
– U9liza9on – Quality of care
• Nothing on postnatal
Next Steps
• Cost-‐Effec9veness • Expand to other Provinces
– Combined with CCT
• Mechanisms – Detailed u9liza9on – Quality of care
• Post natal care and outcomes
Many Thanks to All
Contact informa9on:
Paul Gertler Li Ka Shing Professor of Economics UC Berkeley