Background

Argentina’s constitution guarantees universal health coverage (UHC) for its citizens. Prior to 2004, free health care services were provided through public clinics, but these were chronically underfunded. Provincial governments were responsible for allocating and managing up to 70% of health funding, with little regulation from the Ministry of Health. ¹¹ In parallel, many people with employer-sponsored insurance received care from private providers. 

In 1998, Argentina was hit with a depression that drove many private patients to seek care in the government-run health system, overburdening primary care facilities and exacerbating challenges in providing maternal health services to underserved populations. This shift led the central and provincial governments to agree that increased coordination across levels of government was needed to improve equity and efficiency in the public system.  The central government, in partnership with nine provincial governments and the World Bank, launched Plan Nacer in 2004 to cover pregnant women and children under five. The program (now called Programa Sumar) has since scaled nationwide and covers the general population. A full overview of the program is found here.

Improving budget allocations, funds transfers, and financial management for primary care

Under Plan Nacer, the central government established a new approach to setting provincial budgets. ¹² Sixty percent of the budget allocation from central to provincial level was tied directly to the number of people enrolled in the program by the provinces; provinces were allocated a fixed amount per person in exchange for providing a specific benefit package to enrollees. The remainder of the allocation to provinces was conditional, based on results each province achieved on a set of tracer indicators for maternal and child health service use (see here). The provinces in turn transferred operating budgets to public primary care facilities and reimbursed them on a fee-for-service basis for primary care services included in the mandatory benefit package.

This payment arrangement incentivized provinces to increase the number of people enrolled in the program.  It also incentivized provinces to efficiently transfer funds to front-line providers, because provinces would receive the conditional central government payments based on the utilization of prioritized services at those primary-level facilities. Finally, reimbursing providers for each service provided under the benefit package incentivized providers to increase provision of priority services. ¹³

The central government set overarching guidelines for the use of funds at facilities, and provinces could add additional guidelines to suit their context. Within the guidelines, providers were given autonomy to invest in improving their facilities. ¹³ Permitted expenditures include supplies, maintenance, infrastructure and equipment, staff recruitment, and staff incentives. ¹⁴ Local health authorities retained decision-making authority for full-time staff management, procurement, and service mix at the facility. ¹³ 

Outcomes

The conditional, results-based payments led to an increase in use of services linked to the tracer indicators. According to the Center for Global Development, Plan Nacer averted “approximately 773 neonatal deaths, 1,071 low birth-weight babies, and 25,401 total disability adjusted life years” between 2005 and 2008. ¹¹ A survey of participating providers found that direct payments to facilities improved provider motivation, thereby increasing coverage and quality of services. This has translated to increased patient satisfaction among enrollees. ¹²

Implementation of the program required new or strengthened financial management, disbursement processes, budget implementation, accounting, and monitoring. Providers were required to report to provinces on the number of enrolled patients and health outcomes, and auditing and verification of clinical records for the conditional payments improved record-keeping and data quality. ¹¹ Plan Nacer providers were given extensive training to ensure managerial competency and independent firms were engaged for quarterly audits. ¹³ The monitoring and continuous updating of tracer indicators promoted dialogue between central and provincial governments, rather than top-down control. ¹³ Provincial governments provided support with health planning and ensured that providers had the tools to manage the program effectively. ¹⁴