A presentation from the 2014 Annual Results and Impact Evaluation Workshop for RBF, held in Buenos Aires, Argentina.

2. 2012 Demographic Indicators
Total Population 1,117,463
Area (km2) 29,801
Population density 37.5
inhab/km2
Population eligible for Sumar 386,691
Social Coverage
in 2012
Population
lacking
health
insurance
43.61
%
2012 Infrastructure
Total PublicHospitals 42
# Private health facilities with hospitalstay 63
# Primary Health Care Centers (CAPS) 332
Health providers hired bySumar 331
2012
Morbi –mortality Rate
Birth Rate
Maternal
Mortality
Rate
General
Mortality
Rate
Infant
Mortality
Rate
Neonatal
Mortality
Rate
Post
Neonatal
Mortality
Ratte
22.77 6.68 5.43 11.59 7.31 4.28
Argentina: Province of Misiones
Plan Nacer was implemented in 2005. Program
SUMAR was first implemented in August 2012.

3. SPS Management
PROVINCIAL
INSURANCE
(PSS)
HEALTH
FACILITY
It manages quotas (based on
performance)
Assigns prices to the health
service plan
It hires public health providers
It pays billed services
It enrolls the eligible population
It provides included services
free of charge
It bills the Insurance for the
services provided
It decides on how to invest the
transferredresources
Transfers
additional
resourcesReports
healthservices

4. PSS Pricing
Each of the health servicesincludedinthe healthplan is givena price.
It has to be financially coherent in order to avoid:
Every program that shares the PSS health goals is involved in the pricing
process. Such interaction is defined in the Annual Commitment.
Insufficient balances to pay
the providedservices
Idle balances (theyreveal
low productionor
underutilization ofthePSS)
Supplies
Enrollment plan
Defined production
Prices
Populationcoverage/
Epidemiological incidence
When adjustmentsare requiredto change balances,the controlvariableof the PSS
(HealthService Package)is the price vector(the only endogenousvariable).

5. Use of the ‘Nomenclature’ as a Management Tool in Misiones
File clearance
system (2007)
It eliminated paper invoices (large files with handwritten
invoices and health service reports)
It optimized the monitoring and supervision of productionby
health providers
Automatic control
was implemented,
which had the
following
advantages:
Avoid service duplication
Avoid payingexpiredhealth services (issued more than 6 months ago)
Authorize settlement frequency (based on the agenda)
Relate/condition the settlement ofcertain practices
EXAMPLES:
 Not payingdeliveries or C-sections that have not been reported bymeans of SIP
 Not payingcheck-ups for children between 1 and 6 years of age who have not reported anyvaccines
Condition the payment of active searches (engagement) of children or pregnant women upon check-
ups within 30 days
 Carry out exogenous intervention studies (pay for performance) to check early adoption, children’s
checkups and the joint discharge strategy.

6. 1 • Infrastructure
2 • Equipment
3 • Supplies
4 • Hiring human resources
5 • Training
6 • Incentives for human resources
Use of the Program’sFunds
Health providers decide on
the allocationof the
resourcestransferred by the
SPS.The options are:
From the beginning, Misiones used
part of the resources as human
resource incentives: To improve the income of Human
Resources
To engage Human Resourceswith
Plan Nacer’sgoals

7. 2008
The % of incentives was
subject to compliance
with indicators,with a
minimumof 10% and a
maximumof 50%.
Allocationguidelines
were defined.
2006
50% could be used for
human resource
incentives.
Each health provider
defined allocation
guidelines.
2005
10% could be used for
human resource
incentives.
Percentageswere
defined depending on
whether the HR was a
professional or not.
Human Resource Incentives Policy in Misiones
Program policy allows health providers to allocate a maximum of
50% of the received funds for human resource incentives per
calendar month.
Year 2005 2006 2007 2008 2009 2010 2011 2012 2013
% of funds
for
incentives
10.00% 50.00% 50.00% 25.16% 34.63% 31.47% 27.05% 24.11% 26.87%

8. Incentive Allocation Guidelines
Definitionof
guidelines
dependingon
whetherthe
health provider
is:
A Primary Health Care Center (CAPS): beside the above-mentioned rules,
they must also take into account that:
a) Those who earn the most can never earn more than 5 times the earnings of
those who earn the least.
b) Those responsible for the centers cannot get more than 5% of the total
amount spent on incentives.
c) If beneficiaries obtain incentives for one or more roles, the difference
between those who earn the most and those who earn the least can never be
higher than 5-fold.
A Hospital: make the right to receive the incentive upon compliance with
certain requirements: attendance, effective provision of services, punctuality,
worked hours, productivity,etc.
Allocation guidelines are defined by means of an agreement with the HR that works at the
health center, and this must then be sent to the MSP for evaluation of compliance with
the above-mentioned guidelines.

9. Health Goals for Incentives
Health providers must comply with
their goals based on the type of
service they provide (CAPS or
Hospital) and in accordancewith the
MSP health strategy.
Indicators and goals are updated
regularly.
Each goal is given a certain score that
allows to evaluate whether the
provider complies with the defined
goals in order to allocate up to 50% of
the received funds as HR incentives.
They are monitoredby the system,
which evaluatestheir complianceand
the % that can be allocated on
incentives.The provideris informed
regardingtheir complianceor non-
compliance withthe goals at the time of
payment.
HEALTH GOALS

10. Indicators used for Measuring Performance
CAPS HOSPITALS
Increase in overall enrollment in the municipality where the provider is located
Increase in enrollment of children under 1 year of age in the area where the
provider is located
Engagement of pregnant women before the 20th week of pregnancy
Number of children between 12 and 13 months with MMR vaccine
Number of pregnant women with VDRL
and ATT
Number of pregnant women with VDRL
and ATT prior to delivery
Number of NBs with Apgar higher than 6
at 5’
Number of postpartum women with
sexual and reproductive health
counselling
Number of evaluations of maternal and
infant death cases
Number of women who had a PAP test done
RUSMI Entry (Unified Health Register of Misiones)
Increase in overall CEB in the municipality where the health provider is located

11. Evolution of Enrollment in Plan Nacer 2008-2009
75000
75500
76000
76500
77000
77500
78000
78500
79000
Jan-08
Feb-08
Mar-08
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Enrolled
beneficiaries

12. 3000
4000
5000
6000
7000
8000
9000
10000
11000
12000
2006 2007 2008 2009 2010 2011 2012
Captación Temprana de Mujeres
Embarazadas
Efectividad de Atención en el
Parto y Atención Neonatal
(Apgar)
Efectividad de cuidado prenatal
y prevención de prematurez
(Peso)
Efectividad de Atención Prenatal
y del Parto (VDRL y ATT)
Early detectionof pregnant
women
Effective careat delivery and
neonatalcare (APGAR)
Effective prenatalcare and
prematurityprevention (birth
weight)
Effective prenataland
delivery care (VDRL and ATT)
Evolution of Pregnancy and Delivery Tracers for Plan Nacer

13. Evolution of Enrollment and Overall CEB for Program Sumar 2013 - 2014
328.478
101.092
0
25,000
50,000
75,000
100,000
125,000
150,000
175,000
200,000
225,000
250,000
275,000
300,000
325,000
350,000
Inscriptos
Inscriptos con CEB
26.14% of
eligible
population
with CEB
Enrolled
beneficiaries
Enrolled
beneficiaries with
CEB

14. Analysis of the Utilization of HR Incentives
Advantages Problems
It resulted in an increase of positive cases for
the Program’s tracersand the MSP(Provincial
Ministry of Health) health strategy
 Incentives are consideredan additional
remunerative amount
It increased the health providers’response
capacity
 Low monetary impact
It empowered health providers and their HRs
regardingadjustmentvariables (CEB,tracers)
 The purpose for the incentive payment or
allocationguidelines are unknown
It contributedto the quest for new
performance results on the part of the provider
and their HRs
 Incentives are allocatedwithout checking
the guidelines for productivity,efficiency or
efficacy
 It helped to measure not only productionbut
also the provider’s service quality
 The monetary incentive is not
complemented with non-monetaryincentives
(training,motivation,work atmosphere)
It strengthenedthe SPS supervising,
monitoring and evaluation tasks
 If indicatorsand their goals are not updated
regularly, their positive effect decreases

15. Thank you!