from EVIDENCE to POLICY THEWa BANK Learning what works for better programs and policies February 2015 ARGENTINA: Can Performance Payments Improve Newborn Health? Poor children face barriers to healthy development even before The World Bank actively partners with governments they are born. Their mothers may not have nutritious food or around the world to develop innovative approaches to im- proper prenatal care, which can harm a baby's brain develop- proving lives and boosting shared prosperity. Knowing what ment when it needs it most. Mothers may not deliver in a health works is part of succeeding and impact evaluations often are facility nor have a skilled used to measure whether programs are having the desired birth attendant pres- effect. In Argentina, the World Bank supported a govern- ent, increasing the risk ment program, Plan Nacer, to improve maternal-child health of complications and outcomes through increased coverage and quality of health ultimately putting their services. The program gives provincial authorities financial life and that of the baby incentives for enrolling pregnant women and children in the at risk. How can preg- program and for achieving specific primary health care goals. nant women be assured An impact evaluation found that Plan Nacer improved the that they will receive the birth weight of babies and reduced newborn deaths, while care needed to protect improving access to public health facilities and boosting the children from the worst impacts of poverty while they are at quality of care. The Government of Argentina has scaled their most vulnerable? Governments have successfully used the up the program-now known as Program Sumar-across "pay-for-performance" model to improve the quality and use the country, reaching close to nine million people by ex- of health care, such as increasing vaccination rates or prenatal panding coverage to youth and women below the age of visits. However, this may not be enough to ensure the desired 65. This has since become a model for other Latin Amer- health outcomes. Can payments be linked to actual health can countries, as governments seek to improve health care benchmarks-such as lowering the rate of newborn deaths? for their poorest citizens. An economic crisis in Argentina that broke out in 1998 and for uninsured pregnant women and children under the age of peaked in December 2001 pushed millions out of their jobs six with a special focus on the first year. Plan Nacer provides and into poverty. By 2001, more than half the population was additional funding beyond the existing public health systems living below the poverty level, forcing many to rely on the pub- budgets, while creating incentives to encourage more effective licly financed health system when they needed care. The health use of resources. Provincial governments receive an additional system faltered under the strain of the increased demand just as $5 a month for every pregnant woman or child under the age the government was cutting its own outlays across the board, of six enrolled in Plan Nacer, and up to $3 a month per per- Infant mortality worsened, especially in the poor northern son for meeting the health targets for the eligible population. provinces, where rates were as high as 25 deaths for every 1,000 Health targets are measured by a number of so-called live births. tracers-outcomes that reflect the quality and frequency of In 2004, the Government of Argentina, with financing the care. For example, if pregnant women receive a prenatal from the World Bank, launched Plan Nacer, a health program checkup before their 20th week of pregnancy this indicates that the clinic has succeeded in the goal of early pregnancy responsible for paying clinics according to the level of care detection. Higher birth weights (over 2,500 grams, or five they have provided, based on services delivered to beneficia- pounds) indicate that the clinic's prenatal care is of good ries and billed to Plan Nacer. quality; if children under the age of 18 months are vacci- Plan Nacer was launched in nine of Argentina's poor nated, this shows that the clinic is meeting the immuniza- northern provinces where infant mortality was the highest. tion target. The performance targets for each tracer for each At the time, the nine provinces together had a population province are set annually and measured using administrative of 8.26 million, with an estimated 638,000 uninsured wom- data. The performance payment is divided equally among en and children. By December 2008, enrollment was at 82 the 10 tracers, with payments made based on how well the percent of the eligible population and the participation rate provinces do at meeting the targets. The provinces are then among health providers reached 57 percent. Evaluation Seven of the nine provinces targeted initially by Plan Nacer The evaluation relied on a database specifically created were included in the impact evaluation, which was sup- for this. It used different data sources including birth and ported by the Strategic Impact Evaluation Fund and the medical records at maternity hospitals; the Plan Nacer ben- Health Results Innovation Trust Fund. Researchers relied eficiary roster and Plan Nacer pharmaceutical records at the on the geographic phasing of clinics into the program over individual level; the 2001 population census that included time within each province to create treatment and control the number of eligible mothers in a clinic's area; and the groups. They used the difference-in-difference method to geographic coordinates for health facilities. This data was determine the change in outcomes for people at health clin- merged to create a comprehensive list of the births in ma- ics that were incorporated into the program at the begin- ternity hospitals from 2004 to 2008 in the seven northern ning of Plan Nacer's implementation and clinics that were provinces. This allowed researchers to identify mothers who incorporated into the program later on. The evaluation was had become beneficiaries before birth, the clinic used by the designed to measure the impact of Plan Nacer on beneficia- mother for prenatal care, and the date when the clinic was ries who received care from a Plan Nacer clinic; the impact incorporated into the Plan Nacer program. Researchers then on non-beneficiaries who received care from Plan Nacer analyzed these databases to determine the frequency of pre- clinics; and the impact on the population in general regard- natal visits, quality of care, and birth outcomes. For details less of whether or not they were enrolled in Plan Nacer. of the data analysis, please see the full paper.* The likelihood that a newborn baby would die dropped a hospital with a large maternity practice, defined as at least by 74 percent among Plan Nacer beneficiaries who 1,000 births a year. gave birth in a hospital with a large maternity practice. Women enrolled in Plan Nacer received better prenatal care and they started getting it earlier in their pregnancy. Plan Nacer succeeded in hitting one of its main targets- The clinics they went to had more autonomy in the use cutting the rate of newborn deaths. The 74 percent drop of funds, all of which helped ensure that pregnant women was seen among Plan Nacer beneficiaries who gave birth in got the care necessary to improve their babies' health. Even *This poicy note summarizes the evaiuation discussed in World Bank Policy Research Working Paper 6884, "Rewarding Provider Performance to Enable a Healthy Start to Life: Evidence from Argentina's Plan Nacer" Paul Gertler, Paula Giovagnoli, Sebastian Martinez, May 2014. Available at http://ww-wds.worldbank.org/externaI/ default/WDSContentServerADSP/IB/201 4/05/21/0001 5834920140521140101/Rendered/PDFa/PS6884.pdf women who weren't enrolled in the program but who went The program encouraged accountability and results, to a Plan Nacer clinic for care benefitted: the rate of neona- not just procedures. tal mortality among babies born to these women declined by 22 percent. When the program was designed, provinces received more control over health care because they had a say over how The mortality rate for newborns was reduced to distribute funds to clinics that enrolled in Plan Nacer. thanks to two things-a decline in the probability At the same time, provinces were held accountable because that a baby would be born with a low birth weight, they wouldn't receive funding from the national government and better care for low birth weight babies. unless certain health targets were reached, including enroll- ing more eligible women and children in Plan Nacer. The A babys birth weight is a good indicator of child's Examples of Plan Nacer Targets future health and abilities. Low birth weight, defined First prenatal checkup before week 20 of pregnancy as less than 2,500 grams- APGAR score of over 6 or five pounds-is associ- Birth weight more than 2,500 grams ated with higher rates of Children under 18 months given vaccines infant death, more health Mothers receive reproductive counseling within 45 days problems and delays in of delivery learning later on in life. Preventative checkups for children under 6 The probability of having Staff trained to provide care for indigenous populations a low birth weight baby was reduced by nine per- cent for all women who went to Plan Nacer clinics-regardless two-pronged payment approach gave local governments an of whether the women were enrolled in the program-and for incentive to ensure that clinics enrolled potential beneficia- Plan Nacer beneficiaries, the probability decreased by 19 percent. ries and an incentive to ensure that clinics did a better job The probability of a low birth weight baby dying was cut by taking care of them. more than half if the mother was enrolled in Plan Nacer, com- pared with babies born to mothers who didn't go to a Plan Nacer The program has provided millions of services to clinic. Overall, researchers calculated that 54 percent of the drop the people who need it most, while proving cost in newborn mortality was due to the decline in low birth weight effective in terms of helping people stay healthy. babies, and the remaining 46 percent was due to improved care for babies born under five pounds. In the nine provinces where Plan Nacer started, spending on health care rose 1.4 percentage points to 3.5 percent of Women in Plan Nacer went for more prenatal visits the provincial budgets between 2005 and 2008, for a total and were less likely to deliver by cesarean section. of $107 million spent on the health program. Most of the money, about 71 percent in 2008, went to clinics for ser- Prenatal visits are important because they allow health vices provided to beneficiaries. The second largest category workers to identify problems early on and to provide the was investment in medical equipment and other facility preventive care to protect womens health and the health necessary hardware. Most of this spending happened in the of their babies. Women enrolled in the program were 5.6 first year, when it made up 30 percent of spending, falling percentage points more likely to receive the recommended to eight percent in 2008. As the program has grown, over- tetanus vaccine (translating into almost a 25 percent drop in head costs have decreased, from 16 percent of total provin- the percent of women who didn't get it). There also was a 21 cial health expenditures in 2005 to just 11 percent by 2008. percent drop in birth by cesarean sections-an indication of The program also has been cost-effective when compared quality prenatal care. Overall, for every 100 women enrolled with the number of years of life that could be lost because of in Plan Nacer, there were 68 additional prenatal care visits, illness, disability or early death. Plan Nacer's incentive-based model helped improve mater- programs aimed at improving specific outcomes. As govern- nal and new born health, and ensure that children have the ments around the world look for ways to create effective chance at a good start in life. The evidence from this evalu- programs to help their poorest citizens, the results from this ation will equip policy makers in low and middle income impact evaluation provide an example of how health sector countries with additional information when designing health reforms can give children the right start in life. The Strategic Impact Evaluation Fund, part of the World Bank Group, supports and disseminates research evaluating the impact of development projects to help alleviate poverty. The goal is to collect and build empirical evidence that can help governments and development organizations design and implement the most appropriate and effective policies for better educational, health and job opportunities for people in developing countries. For more information about who we are and what we do, go to: http://www.worldbank.org/sief. The Evidence to Policy note series is produced by SIEF with generous support from the British government's Department for International Development. THE WORLD BANK THE WORLD BANK, STRATEGIC IMPACT EVALUATION FUND 1818 H STREET, NW WASHINGTON, DC 20433 Produced by the Strategic Impact Evaluation Fund Series Editor Aliza Marcus; Writer: Daphna Berman