2013年-世界发展银行全球_Argentina_-_Increasing_Utilization_of_Health_Care_Services_among_the_Uninsured_Population___The_Plan_Nacer_Program_38页_1mb

Summary of UNICO Studies Series 12: Argentina's Increasing Utilization of Health Care Services among the Uninsured Population – The Plan Nacer Program

Core Content

The document outlines the Plan Nacer Program, an innovative initiative launched in Argentina to expand health care coverage and improve the efficiency of the health system for the uninsured population, particularly pregnant women and children under six years of age. It is part of the World Bank's Universal Health Coverage (UHC) Studies Series (UNICO Study Series), which aims to support countries in implementing UHC strategies by providing technical insights and case studies.

The program was introduced in response to the 2001 economic crisis, which led to a significant increase in poverty, unemployment, and the number of people without health insurance. This crisis exacerbated health inequalities and worsened health indicators, especially in poorer regions. Plan Nacer was designed to address these challenges by introducing results-based financing mechanisms and strengthening governance and stewardship in a decentralized health system.

Main Objectives of Plan Nacer

• Increase access to essential health services for the uninsured population.
• Improve health outcomes for pregnant women and children.
• Enhance the efficiency of the health system through performance-based incentives.
• Strengthen the governance of the public health system at the national and provincial levels.

Key Features

• Results-based financing: Funding is tied to the achievement of specific results indicators, including enrolment, delivery of priority services, and health outcomes.
• Incentive mechanisms: Contracts between the national government and provinces, and between provinces and health service providers, include enforcement mechanisms to ensure accountability and performance.
• Monitoring and evaluation: The program includes a robust monitoring and evaluation framework, with internal and external audits and an impact evaluation strategy.
• Targeted population: The program focuses on uninsured and vulnerable groups, especially pregnant women and children under six.
• Institutional framework: The program operates within the existing federal structure, where provinces are responsible for delivering services, and the national government coordinates the system.

Implementation and Outcomes

• Plan Nacer has enrolled over 4.5 million beneficiaries since its launch in 2004, with 1.84 million beneficiaries by April 2012.
• Positive outcomes include increased prenatal care visits, improved quality of care, and better birth outcomes (higher average birth weight and lower incidence of very low birth weight).
• For children under five, the program increased the likelihood of receiving well-baby checkups.
• The program was successful due to its strategic use of financing, contractual enforcement, and results-based approach, rather than drastic reforms.

Challenges and Lessons

• The program's success was built on an existing but underperforming health care network, highlighting the importance of reforming incentives rather than overhauling the entire system.
• Pending agenda includes:
  • Developing sound health information systems.
  • Enhancing monitoring and evaluation tools.
  • Implementing clinical protocols.
  • Ensuring program sustainability.
  • Addressing equity across provinces.
  • Establishing a standardized process for setting priorities based on clinical and cost-effectiveness studies and social validation.

Health System Overview

• Argentina's health system is highly fragmented, with three main subsystems: public, social security, and private.
• Public health expenditure constitutes 27.3% of GDP, with provinces accounting for 68% of public health spending.
• Social security covers 38.7% of total health expenditure, mainly through payroll taxes.
• Private health expenditure accounts for 33.9% of total health expenditure, driven by out-of-pocket payments and voluntary insurance.

Funding and Delivery Mechanisms

• Health services are delivered by public, social security, and private providers.
• The public sector includes 24 provincial ministries of health and the Autonomous City of Buenos Aires, as well as the national Ministry of Health (MOH).
• Primary care is the main level of care for the uninsured population, though it faces efficiency challenges and inadequate access in vulnerable and rural areas.
• Referral and counterreferral systems are underdeveloped, limiting the effectiveness of health networks.

Stakeholders and Roles

• National Government: Coordinates the health system, sets standards, and manages results-based financing.
• Provincial Governments: Deliver and fund health services within their jurisdiction.
• Local Governments: Support health service delivery in some provinces.
• Health Service Providers: Receive additional funding based on service delivery outcomes.

Conclusion

Plan Nacer represents a successful model of results-based financing that has significantly improved health service utilization and health outcomes for the uninsured. It has demonstrated the importance of targeted investment, contractual accountability, and performance-based incentives in achieving UHC. The program's lessons are valuable for other countries aiming to implement similar strategies, particularly in low- and middle-income settings with decentralized health systems.

Key Figures and Tables

• Total health expenditure in Argentina in 2009 was 9.4% of GDP, with public spending at 27.3% and social security at 38.7%.
• Provincial health expenditure increased from US$7.3 billion (2003) to US$30 billion (2009).
• Personnel expenses accounted for 61% of provincial health expenditure in 2010.
• Health service delivery is managed by public, social security, and private subsystems, with public services primarily used by the uninsured and poor.

Annexes

• Annex 1: Plan Nacer's Tracers – indicators used to measure program impact.
• Annex 2: Main Stakeholders – roles and responsibilities of different entities in the program.
• Annex 3: Argentina's Health Sector in Numbers – statistical data on health expenditure and service delivery.