2009年-世界发展银行全球_Argentina_-_Provincial_Maternal_and_Child_Health_Insurance___A_Results-Based_Financing_Project_at_Work_4页_2mb

Summary of Argentina's Provincial Maternal and Child Health Insurance Program (Plan Nacer)

Core Content

Plan Nacer is an innovative results-based financing program implemented in Argentina to improve maternal and child health and reduce health inequity. Launched in 2004 with support from the World Bank (initial loan of US$135.8 million), it was expanded to all provinces in 2006 with an additional US$300 million loan. The program targets the most vulnerable populations, particularly uninsured pregnant women and children under six, and provides a free basic package of cost-effective services through contracted healthcare providers.

Main Viewpoints

• Inequity in Healthcare Access: Despite high public health spending, access and quality of healthcare remained poor for the uninsured and poor populations, especially in the poorest provinces.
• Program Design: Plan Nacer focuses on target populations and uses a two-step financing mechanism based on enrollment and performance.
• Results-Based Incentives: The program uses 10 health indicators (Tracers) to measure performance. Provinces receive 60% of funding upon enrollment and 40% after meeting Tracers.
• Institutional Reforms: The program led to significant institutional changes, including improved governance, transparency, and accountability.
• Impact on Health Outcomes: There was a substantial improvement in health indicators, such as prenatal care utilization, immunization rates, and child mortality.

Key Information

How Plan Nacer Works

• National Ministry of Health:
  • Provides funds to provinces on a per capita and performance basis.
  • Sets service standards and supervises compliance.
• Provincial Governments:
  • Identify and enroll the target population.
  • Contract healthcare providers to deliver services.
  • Establish Provincial Insurance Units to manage the program.
• Healthcare Providers:
  • Deliver a cost-effective package of services.
  • Are reimbursed on a fee-for-service basis.
  • Can use up to 50% of funds to incentivize staff.

Financing Mechanism

• Capitation transfers are based on the number of registered beneficiaries.
• 60% of funds are disbursed monthly upon enrollment.
• 40% of funds are released after meeting Tracer indicators.
• The Nomenclador defines the service package and allows for semi-annual price reviews.

Supervision and Audits

• Management agreements are signed between the National and Provincial Governments and Healthcare Providers.
• Internal and independent audits are conducted every four months.
• Performance Agreements ensure compliance with targets.
• Feedback mechanisms are used to correct mismanagement and improve program functioning.

Results of Plan Nacer

• As of September 2009, the program reached 80% of its target population.
• Prenatal care utilization increased from 3% to 52% in the poorest provinces.
• Immunization rates rose from under 66% (1996) to over 94% (2007) for children under 12 months.
• Child mortality rates declined from 25 per 1000 live births (1996) to 15 per 1000 (2007).
• Infant mortality began to decline again after the 2001 economic crisis, with faster reductions in poorer provinces.
• A service tracking system was developed to monitor individual beneficiary services and improve resource allocation.

Institutional Changes and Effective Financing

• The program locked in institutional changes, such as improved governance and financial independence for providers.
• Detailed data on health outcomes and service delivery was collected and used for monitoring and evaluation.
• Effective communication between national and provincial governments improved policy-making and implementation.
• Annual investment of over US$50 million contributed to major improvements in the health sector.

The World Bank's Role

• The World Bank provided financial and technical support for over a decade.
• It helped integrate results-based financing into the national health system.
• Bank funds were disbursed only after verification of tracer targets.
• It supported monitoring systems, policy updates, and service package improvements.

Future Challenges

• Financial sustainability needs to be strengthened.
• Integration between primary care and hospitals should be improved.
• More complex health interventions should be included in the service package.
• Incentive mechanisms at the facility level need to be developed.
• Health indicators should be monitored under the national system.

Conclusion

Plan Nacer has demonstrated the effectiveness of results-based financing in improving health outcomes and reducing inequity. By focusing on target populations, contracting with providers, and using performance indicators, the program has made significant strides in maternal and child health. However, it faces ongoing challenges in scaling up and sustaining its success in the long term.