Performance-Based Intergovernmental Transfers Brazil’s Family Health Program and Argentina’s PLAN NACER Program Jerry La Forgia With thanks to Rena Eichler and Christian Baeza
Jan 16, 2016
Performance-BasedIntergovernmental Transfers
Brazil’s Family Health Programand
Argentina’s PLAN NACER Program
Jerry La Forgia
With thanks to Rena Eichler and Christian Baeza
Summary
• Brief overview of results-based financing• Brazil ‘s Family Health Program
– incentives to increase coverage– Pilot incentive scheme to increase coverage,
efficiency and effectiveness• Argentina’s Plan Nacer
– Results-based model– Financial flows– Indicators
Why consider Results Based Financing?Business as usual is not working
• Problems– Coverage/utilization/access– Uptake of preventive services– Quality– Volume– High OOP spending
Many labels
• Pay for Performance or “P4P”• Results-Based Financing or RBF• Performance-Based Financing• Output-Based Financing• Performance-Based Contracting• Performance-Based Incentives• Conditional Cash Transfers• Conditional Cash Payments
Concept
Payers(Government, Health Programs, Insurers,
Communities)
Payers(Government, Health Programs, Insurers,
Communities)
Recipients(Households, Service Providers (Facilities, Health Workers), Health Programs, Sub-National Levels
of Government
Money,Goods,
Other Rewards
Well-defined and measureable
results
Levels to consider: from payer to recipient
Demand Side (Household, Individual)
Types of Approaches(supply side)
• Pay for quality– Pay for structure (e.g., personnel, training)– Pay for process (e.g., use of protocols, patient
tracking, – Pay for accreditation– Pay for mistake prevention (e.g., control of adverse
events)– Pay for outcomes (e.g., reduction in readmissions)
• Pay for targeted service delivery (e.g., immunizations)
• Pay for production or utilization• Pay for insurance coverage• Pay for information collection and reporting
Types of Approaches(demand side)
• Pay for healthy behaviors (e.g., program participation and retention; reduce rates of highly additive behaviors; smoking cessation )
• Paying for health care behaviors (e.g., preventive visits, follow-up visits, blood pressure control, immunizations, institutional deliveries, etc.)
Possible Pitfalls• Excessive attention to reaching targets to detriment of other
interventions or services• Undermining intrinsic motivation, turning health care
delivery into “piecework”• “Gaming,” – managing the metric• Cream skimming • Institutional readiness
– Rules of game (ex. Agreement/contract, stakeholder consultations)– Pay on time– Define measureable indicators– Monitor and verify indicators (catch “inflators”)– Enforcement (political interference)– Degree of provider autonomy (let managers manage)
Other Issues
• The problem of small numbers• The luck of the draw (or not)• How much of an incentive is needed to
capture provider attention?– Dependent on provider transaction costs?
What about impact?• Studies with robust methods and samples are far
and few between• Many experiments underway• Results so far -- Mixed bag for provider-targeted
incentives– Some improvements– Providers do respond to incentives– Attribution problem; unclear causal linkage– Ad hoc interpretations
• More robust results for patient-targeted incentives– Addictive behaviors and care behaviors
Lessons Learned• In-flight adjustments are common as scheme matures• P4P costs!
– Finding resources to sustain program– Need for TA investments
• Plateau effect– How to incentivize continuous improvements?
• Burden/cost of data collection– Ensuring data validity
• Perverse effects– Lower volume/quality for activities not incentivized
• Incentives may be too weak to overcome other incentives embedded in payment mechanism
Getting from Here to There1. Assess and prioritize performance problems2. Consult stakeholders3. Select recipients4. Define indicators, targets and how to measure them5. Set payment rules, sources of funds, and how funds
will flow 6. Determine management and operational roles and
systems– Establish contracts/agreements– Routine Monitoring– Validation– Payment– Assess and revise
Inter-governmental Transfers
Brazil’s Family Health Program
Institutional ReadinessFinancial system reform
• How to make federal government financing for health more effective and less cumbersome?
• How to make subnational entities (states and municipalities) more accountable for use of federal financing?
Old System
GoB
MunicipalTreasury
Statetreasury
StateHealth
Secretariat
MunicipalHealth
Secretariat
Services, Programs,Investments
Services, Programs,Investments
MUNICIPALHEALTHFUND
FEDERALHEALTHFUND
Transfers
Brazil Federal Financing Subsystem for Health Implemented by Municipalities
StateHealth
Fund
Transfers
MUNICIPALHEALTH
SECRETARIAT
FEDERALHEALTH
MINISTRY
Paymentmechanisms
Privateproviders
Publicproviders Bene-
ficiaries
The Case of the Family Health Program (PSF)
• 1994+• Primary care program• Active outreach and prevention
– Tracking of family and community health– Based on Family Health Approach
• Team: doctor, nurse, nurse auxiliaries and community health agents
1. Women´s health pre-natal care, prevention of cervical cancer, family planning
2. Child health growth & development, nutrition, immunization, treatment of prevalent illnesses
3. Control of hypertension4. Control of diabetes5. Control of tuberculosis6. Elimination of leprosy7. Prevention of, testing and counseling re. HIV including
prevention and treatment of STIs8. Oral health9. Health promotion activities10.Population-based health activities
PSF: Original Priority Areas
PSF Performance-based Financing Scheme
• Problem: slow uptake of program by municipalities
• Objective: Provide incentives to municipalities to establish program and expand to poorest Brazilians– Flat one-time transfer for establishing each new
PSF team– Variable transfer to incentivize continuous
coverage extension (co-financed recurrent costs of teams)
Level Population Coverage Amount per team per year ($R)
1 0 to 4.9 % R$ 28.008,00
2 5 to 9.9 % R$ 30.684,00
3 10 to 19.9 % R$ 33.360,00
4 20 to 29.9 % R$ 38.520,00
5 30 to 39.9 % R$ 41.220,00
6 40 to 49.9 % R$ 44.100,00
7 50 to 59.9 % R$ 47.160,00
8 60 to 69.9 % R$ 50.472,00
9 70 % and more R$ 54.000,00
Financial Incentives for Family Health Program (2002)
Annual Number of PSF Team, 1994-2008
Pilot Scheme (2009+)
• Improve coverage, effectiveness, quality and efficiency of PSF in large cities
• Financing varies according to compliance with indicators
• Can earn additional 15% bonus for participation and establishment of quality certification program for PSF
PERFORMANCE-BASED INCENTIVE SCHEMEFOR PARTICIPATING MUNCIPALITIES
(variation in per PSF team allocations according to performance category)
(a)
$2X(b) (c)
$2.5Xmaximum per teamAllocation
(d) (e) (f)
(g)$X
minimum per team allocation
(h) (i)
$1.5X
Efficiency, Effectiveness, Fiduciary Improvement
Coverage Im
provement
IndicatorsEffectiveness
1. Increase in per capita medical visits PSF teams2. Infants <1 with complete vaccination regimen (DPT-H, polio, measles, tuberculosis)3. Pregnant mothers with 7 or more pre-natal consultations4. % patients referred from Family Health teams for specialized care over total number of PSF medical consultations
Efficiency5. % reduction of hospital admissions for stroke6. % reduction of hospital admissions for children <5 for acute respiratory infections (ARI) Management7. PSF teams supervision Supervision plan (objectives, schedule, checklist) No. of municipal supervisors PSF teams supervised (with verified supervisory report)8. % PSF teams trained in at least 4 PSF strategic areas
Argentina’s Plan Nacer
Financing Health Sector Results
• Problem– Inequitable distribution of resources across
states and w/I states– Many poor Argentines lost health insurance
during economic crisis of 1997-2002– Increase in IMR and MMR rates
• Objective– Increase access to basic health services for
uninsured mothers (during pregnancy) and children (up to 6 years old), contributing to decrease infant and maternal mortality
– Target the poorest states (600,000 beneficiaries)
PLAN NACER
New Results-based Transfer model• Introduced financial incentives between the federal
government and provinces (states) and between the states and public and private providers, linking financing with results (output and intermediary outcomes).
• Established MCH package of services• Created capitation-based grant transfer based on
cost of MCH package– 60% of the capitation payment released upon monthly
certification of enrolment of eligible population, and – 40% of the capitation payment released for each of the 10
Tracers goals achieved (quarterly, ex-post audited by a concurrent auditor)
Funding flows
StateHealth
Authorities
FederalHealth
Ministry Privateproviders
Publicproviders
Provision of servicepackage
Per capita –Based Transfers
60% on verified enrollment
40% on verifiedTracer indicators
Fee-forservice
Auditor
Provision of documentation on
enrollment and services
Fund releases triggeredby verification of outputs
TRACERS•Timely inclusion of eligible pregnant women in prenatal care services•Effectiveness of neonatal and delivery care (Apgar Score)•Effectiveness of pre-natal care and prevention of premature birth (weight above 2.5 kilos)•Quality of pre-natal and delivery care ( number of mothers immunized and tested for STDs)•Medical Auditing of Maternal and Infant deaths•Immunization Coverage (measles vaccine)•Sexual and Reproductive Healthcare•Well child care (1 year or younger)•Well child care (1-6 years old)•Inclusion of Indigenous Populations
Design Elements• Certification by Independent Concurrent
Auditor
– Certification of beneficiary eligibility is done by the Concurrent Auditor through monthly cross-checking of beneficiary databases and enrolment registers.
– Certification of Tracers is done by the Concurrent Auditor through both, certifying surveillance and monitoring systems at provincial and provider levels as well as through sample auditing of medical records at provider level
– Penalties for erroneous billing (125% of capitation is discounted)
Design Elements• Fee-for-service payment to public and private
providers• Providers can use up to ½ of payment to pay staff
bonuses• Free choice of provider• State governments
– Enroll beneficiaries– Establish purchasing/contract management unit– Contract providers– Strengthened surveillance and monitoring systems
required to certify achievement of tracers
ResultsAPL-1 Tracer Accomplishments:
Goal vs.Outcome
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
1 2 3 4 5 6 7 8 9 10Tracers
Pe
rce
nt
Ac
co
mp
lish
ed
Goal
Outcome
Business as Unusual
• For the first time in Argentina and Brazil’s public health sector, national financial transfers to the states and municipalities are linked to verifiable results.
• Also for the first time, in Argentina financing of public providers is done on the basis of delivery of services to eligible population. In Brazil, financing based on no. of enrollees, and more recently, reaching performance benchmarks
• New output and outcome data is beginning to serve as basis for strategy and planning at federal, state and municipal level