Sabignoso – National Coordinator, Plan Nacer/Sumar – Argentina
The national coordinator of Plan Nacer and Plan Sumar – two social security programs to improve access to healthcare in Argentina – discusses universal coverage as a constitutional right, and the history of the two programs so far.
Can you please give our readers a brief summary of the activities of Plan Nacer and Plan Sumar, from its conception to the present day?
Plan Nacer started operating in 2004. Our mission is to reinforce public health coverage for those who don’t have formal health insurance. It was launched after an economic crisis that increased poverty and worsened health outcomes for poor women and children. Our philosophy is to cover primary health care with preventive and promotive health services instead of treating specific diseases. Plan Nacer uses an innovative “pay for performance” model that provides incentives to the provinces and health care centers to promote better access and quality of health services.
Before launching the program, we noticed some strengths and weaknesses of the “universal coverage” program, financed by the federal budget and guaranteed by the constitution, and tried to fill in those gaps. In previous systems, Social Security recipients had free access to a list of services; Plan Nacer invested additional resources that complement the existing ones by using an innovative result-based financial scheme.
When this plan started, we just covered a handful of provinces, and we provided public health insurance to uninsured pregnant women and children under the age of six. By 2007 we reached most of the Argentinian territory, and in 2012 with the establishment of Plan Sumar (which now manages Plan Nacer) we have extended our services for children from 6 to 19 years of age, and women up to 64. As we speak, we are providing coverage to more than 9 million people!
What have been the key successes of the program so far?
Since our program started, low-income Argentinian women (and children) received an improved health service that led to a significant decrease in low birth weight and in-hospital deaths of babies in the first 28 days of life. All of our achievements were monitored and confirmed by the World Bank and the University of California, Berkley. Through Plan Nacer, the national ministry of health has gained influence over the management of health issues at the provincial level, as we disburse funding based on the attainment of certain targets set at the federal level.
We are also working to develop a new management culture in the public sector. In terms of technological achievements, we have developed online IT systems that systematically monitor the utilization of prioritized services. This has given us greater visibility on who is using our services and which services are being used, and other data that helps us to manage the Plan effectively.
Could you explain how the results-based financing model is unique and how does it differ from other performance-based financing models?
The first distinguishing feature is that we use a pay-for-performance in the relationship between the government and the provinces; this is quite unique. If you want to move forwards towards a big contract change you cannot rely exclusively on one instrument, you need a combination of different methods; this is why Plan Nacer’s design is very consistent. Our program also introduces incentives to provincial governments and to public clinics; we provide autonomy because they are key players in this financing model. Argentina has a decentralized health system, but our program seeks to create space to build consensus and harmonize treatment standards, so it is critical that we include the provinces in our planning and prioritization process.
The success of Plan Nacer has derived from the usage of situational approach. It was very clear to us that we needed to strengthen and empower the existing structure without changing its values and organization. We respect the autonomy of every province and municipality and always try to create a cooperative relationship with the provinces without interfering too much in their decisions; as long as we in agreement over the main objectives, our operations only seek to provide incentives and tools to empower the local health authorities to achieve these objectives in the way best suited to the local environment.
Results Based Financing can be really useful to any country; it is a complex, demanding, yet powerful system. The first building block is to have a multidisciplinary team to lead this strategy, otherwise it can be really frustrating. RBF is complex but not impossible. It can be the nucleus of a deep cultural change within the health care system and the platform for an ambitious change within public organizations that pursue excellence. It is about building quality-based organizations. With this new instrument, every country can aspire to excellence; not only rich and developed countries can achieve excellence, but every single country in the world!
What have been the biggest challenges for Plan Nacer and plan Sumar?
When this program was launched, the incentive that Argentinian provinces and facilities valued the most was money, however, over the years, they have increasingly valued the philosophy that we advocate, our leadership role, and the virtuous cycle of continuous improvement that we have introduced.
The initial challenge was get money to the facilities themselves in such a way that it was spent efficiently and on items that would improve the capability and motivation of the health teams. These facilities are usually financed through the provincial budget, and the health teams on the ground had little control over how the funds were allocated, so when we distributed funds directly to the facilities, this was such a significant change that in the beginning they were very skeptical and doubted that they would continue to receive funds as we promised. Once they realized that we were serious and trust worthy, they started to analyze their options carefully and make wise and appropriate decisions as to how to spend the funds to improve their work conditions and patient care capabilities. The key point is that there is a lot of health team motivation and that brings a high level of participation. This strategy has proven to be a more reliable option and a great part of the credit goes to the strong leadership and credibility that we have; we never missed making the monthly payments to the providers and we are always trying to promote innovation as well a better quality learning process among our provinces, we always listen to what they have to say.
Our main challenge was to develop new management skills, and a more professional management culture at all levels of the public system: national, provincial and facilities level. This has been particularly difficult to achieve in the facilities themselves. Our goals are quite demanding and constitute a significant challenge to the status quo, as we require everyone to learn new procedures, operational standards, and a new philosophy, all of which force individuals to work much harder to achieve the same productivity, albeit at a significantly higher quality. At the provincial level we’ve had some success in shifting the mentality towards public healthcare, and now the provincial governments have added the term “good practices” to their vocabulary and some of their legislation.
What gaps remain to be filled?
One gap that remains the health of adolescents, as in general they are not cognizant of the importance or existence of the services we provide, and in general are not particularly concerned about maintaining their own health. This is a gap that represents a lot of work for us. Plan Nacer and Plan Sumar use gradual strategies, we need to go in small steps, otherwise the whole thing could fail. It’s an impossibility to close all gaps in a reduce time frame; closing them will take several years.
In terms of additional services, we would like to extend our coverage of men up to 64 years of age, when they start being covered by PAMI. Every achievement brings a new challenge, and this will continue to be a slow ongoing process. In order to sustain an institutionalized policy and continue to make progress, it is essential that we strengthen alliances and cooperation with other stakeholders, including the education system, social security institutions, and private health insurers sectors.
Now that you’ve seen a lot of success with these variables, what areas will need to be improved?
We’re trying to build a more comprehensive research agenda, using instruments such as qualitative and mixed measures. We will continue using impact evaluation with the help of the World Bank, as we try to fine-tune our pay-for-performance scheme and our audit system. Our goal is to develop a set of instruments and methods that are easily adaptable to the new challenges; our skills must evolve over time to keep our effectiveness at the highest levels. In 2016, we will be promoting some changes in the healthcare approach for non-communicable diseases.