Success beyond numbers: The Salud Mesoamerica Initiative’s results- based financing approach to improve health services for the poorest in Mesoamerica World Bank BBL Presentation Social Protection and Health Division- Inter American Development Bank Emma Margarita Iriarte, Executive Secretary of SMI
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Success beyond numbers: The Salud Mesoamerica Initiative’s results-based financing approach to improve health services for the poorest in Mesoamerica
World Bank BBL PresentationSocial Protection and Health Division- Inter American Development BankEmma Margarita Iriarte, Executive Secretary of SMI
What does SMI aim to change?
Only 1 of every 2 pregnant women in the poorest 20% gives birth assisted by skilled personnel
Twice as many children <5 years of age in the poor population die compared to the regional average
A 5-year-old child from the poorest 20% is6cm shorter than a child from the wealthiest 20%
x2
What does SMI aim to change?
SMI areas: baseline situation (2012) – child health
Chiapas El Salvador Guatemala Honduras Nicaragua Panama
(%)
27.8
59.1
12.5
31.5
48
9.9
39.446.5
68.8
35.3
53.9
73.6
41.8
14.6
62.1
23.6
13.3
55.9
Complete vaccination for age, according to vaccine card
Anemia, children 6-23 months
Stunting, children 0-59 months
Population Health Metrics, 2015: Salud Mesoamérica 2015 Initiative: design, implementation, and baseline findings
SMI areas: baseline situation (2012) – quality of care
* Information on equipment and inputs is not available
10.8
3.6
13.1
2.9
0
0
6.9
0
7.5
4.4
0.6
11
0
2.6
Nicaragua
Chiapas
Honduras *
Guatemala
Belice
Unidades de salud condisponibilidad permanente deequipos e insumos para laatención de la emergenciaobstétrica y neonatalNeonatos con complicaciones(bajo peso, prematurez, asfixia,sepsis) atendidos de acuerdo a lanorma
Mujeres con complicciones (pre-eclampsia eclampsia, sepsis,hemorragia) atendidas de acuerdoa la norma
Health facilities with continuous availability of equipment and inputs for emergency neonatal and obstetric care
Neonates with complications (low birth weight, prematurity, asphyxia, sepsis) treated according to the norms
Women with obstetric complications (pre-eclampsia, eclampsia, sepsis, hemorrhage) treated according to the norms
(%)
What does SMI aim to change?
SMI areas: Crude vs Effective Coverage of Measles Immunization in Mexico and Nicaragua
Chiapas, Mexico Nicaragua
Citation: Colson KE, Zúñiga-Brenes P, Ríos-Zertuche D, Conde-Glez CJ, Gagnier MC, Palmisano E, et al. (2015) Comparative Estimates of Crude and Effective Coverage of Measles Immunization in Low-Resource Settings: Findings from Salud Mesoamérica 2015. PLoS ONE 10(7): e0130697. doi:10.1371/journal.pone.0130697
Performance indictors linked to changes in national norms and protocols (1st Operation)
Country Policy Dialogue Indicator – Updated Norm Status
Belize• Quality of reproductive and child health services• Establishment of a community platform of services
Completed
El Salvador
• Micronutrient powders to reduce anemia and zinc fortreatment of diarrhea
Completed
Honduras• Common childhood diseases• Micronutrient powders approved
Completed
Nicaragua • Community platform and nutrition interventions Completed
Panama • Inclusion of zinc for diarrhea treatment Completed
Measurement and Monitoring through:
Mapping of key clinical and management processes and standards
Clear surveillance data on gaps in performance to set aims and priorities
QI Teams in three levels of the system
Reflection/learning embedded: plan-do-reflect-act
Use of data for improvement (not only for accountability)
Rapid testing to learn and improve as quickly as possible harvest best practices
Alignment of incentives
External surveys: verify performance framework and monitors regional results framework.
Quarterly monitoring: proxy indicators from health information systems.
Monthly monitoring: advances in key products in project execution plans, physical and financial progress.
Qu
alit
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SMI first round of results (18-24 months)
Very sizeable changes in the supply of essential health care in a short period in all countries
69% of the 83 negotiated targets met in 8 countries
Costa Rica, El Salvador, Honduras, Nicaragua and Panama received the performance tranche (PT)
Belize, Chiapas and Guatemala mastered an impressive progress but fell short of the cut off to receive the PT
Chiapas, Guatemala implemented an improvement plan, with their own resources, were re-measured and achieved all the targets
Honduras: success stories
Baseline(%) 18-Month(%)
Indicator data 0 50
Resuscitation bag for adults 83,3 100
Neonatal resuscitation bag 100 100
MVA kit 66,7 100
Stethoscope 66,7 100
Sphygmomanometer 83,3 100
Pinard stethoscope/portable doppler 100 100
Oxygen tank 83,3 100
Autoclave/dry heat sterilizer 66,7 83,3
Pediatric/neonatal stethoscope 0 83,3
Laryngoscope 100 83,3
Anesthesia kit 66,7 66,7
Uterotonics1 100 100
Tetracycline eye ointment 16,7 100
Saline wash 66,7 100
Saline solution or Ringer's lactate 83,3 100
Magnesium sulfate 100 100
Anti-hypertensives2 100 100
Naloxone hydrochloride 83,3 100
Furosemide 100 100
Phenobarbital sodium 100 100
Diazepam 100 100
Dextrose 66,7 100
Dexabethasone/ betamethasone3 66,7 100
Sodium bicarbonate 100 100
Antibiotics4 100 100
Adrenaline 100 100
Atropine/epinephrine 100 100
Health facilities with availability of supplies, medicines and equipment for
neonatal and obstetric emergencies in hospitals
Equipment
Pharmacy inputs
Chiapas: success stories
0
10
20
30
40
50
60
70
80
90
100
Baseline
18-Month
PIPM
Child care Antenatal
and
postpartum
care
Emergency
obstetric and
neonatal
care
Delivery and
newborn
care
Family
Planning
*All percentages reflect the Performance Improvement Plan Measurement (PIPM) definitions with no stock-out
perc
ent
Belize: success stories
Health facilities with availability of equipment for child care (“heat map”)
Taking stock of SMI: voices from the countries*
*In depth interviews with a sample of national and district level leaders of the Ministries of Health (independent evaluation by Rena Eichler and Susan Gigli).
Positive Aspects
• Overall feedback is highly positive
• Management by results is new and perceived as catalytic and creates new partnerships
• SMI is enhancing Know-How
• New evidence based strategies and results oriented interventions are being introduced.
• Supply systems are being strengthened
Challenging Aspects
• Short Timelines
• Some targets were too ambitious
• Construction of some indicatorscould be improved
• Initial incomplete understanding of what needed to happen to achieve targets
• Frustration with the country’s own systems and their capacity to move quickly
Moving forward
Next set of targets are much harder: coverage and quality of interventions and selected outcomes (population-based results)
Addressing funding gaps
Continue facilitating technical assistance and collective learning and innovation.
Sustainability: how to maximize the likelihood that system enhancing changes will be sustained?