A presentation by Pablo Celhay, Paul Gertler, Paula Giovagnoli and Christel Vermeersch, delivered at the RBF Health Seminar, On the Road to Effective Universal Health Coverage: What’s New in Argentina’s Use of Performance Incentives? on June 11, 2015.
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Long run effects of temporary incentives on medical care productivity in Argentina
1. J U N E 1 1 , 2 0 1 5
P A B L O C E L H A Y
P A U L G E R T L E R
P A U L A G I O V A G N O L I
C H R I S T E L V E R M E E R S C H
Long Run Effects of Temporary Incentives
on Medical Care Productivity
2. TEMPORARY INCENTIVES HAD A LONG -
RUN IMPACT ON MEDICAL CARE
PRODUCTIVITY
TEMPORARY INCENTIVES HELPED
OVERCOME THE INITIAL COST OF
IMPROVING MEDICAL CARE ROUTINES
Main findings
3. Routines in medical care
Medical care is a
complex technology
Coordination of
team activities is
key
Routines =
“Established rules”,
“standard operating
procedures” that
become habits
4. Institutions have a hard
time changing their
routines.
.. It takes effort
.. It takes time
.. It might be costly
5. Medical care routines can be suboptimal
E.g.: Adherence to clinical practice guidelines (best-
practice) is low.
18%
24%
45%
46%
50%
60%
67%
75%
81%
84%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
India - Diahrrea
Tanzania - Malaria
Rwanda - Prenatal Care
Indonesia - Tuberculosis
USA - Preventive Care
USA - Chronic Conditions
Netherlands - Family
Mexico - Prenatal Care
UK - Diabetes
UK - Asthma
Adherence to CPG
Source: Authors’ elaboration based on Schuster et al. (1998); Grol (2001); Campbell et al. (2007); Das and Gertler (2007); and Gertler and
Vermeersch (2012).
6. Role of incentives – causal chain
Initial/Upfront cost inhibits change of routines
Financial incentives may help overcome this initial
cost
Once the institution adopts new routines, it will
continue them as long as recurrent costs are covered.
8. The Misiones experiment
Aim: Increase the probability that 1st prenatal visits take place in first
trimester
In primary care setting
Intervention: Temporary (8 months) increase in fees
40
120
40 40
0
20
40
60
80
100
120
140
Pre & post periods Intervention period
Fee-for-service payment for 1st prenatal visit before week 13
Treatment Control
+200%
A
r
g
.
P
e
s
o
s
9. The Misiones experiment
Identification strategy:
Randomized assignment of 37 primary care clinics to
treatment and control
Assignment not fully respected (but close enough) use IV
estimator
Treated Not treated
Assigned to
treatment
14 4
Assigned to
control
1 18
11. Data
Clinic records
services delivered
Registry of Plan Nacer
beneficiaries
beneficiary status of the
mother
Hospital medical records
birth outcomes
link using the
mother’s national
identity number
15. Density of birth weight
Pre-intervention Intervention
We do not find an impact on birth weight.
16. C H A N G E S I N R O U T I N E S
E V I D E N C E F R O M I N - D E P T H I N T E R V I E W S
Mechanisms
17. What did treatment clinics do?
Change in assignment of incentives to personnel
Conditioned on number of women brought in
Change in routines to improve efficiency of outreach
by community health workers
Offer pregnancy tests to mothers when picking up milk for
their children
Visit adolescents when parents aren’t home
Visit women who abandoned birth control pills
Organize the Ob/Gyn schedule to ensure predictability of
service
18. Increase in maternal-child “hits” due to outreach
Treatment and
comparison clinics
equally paid for outreach
activities that result in
actual maternal-child
service at the clinic
19. Why no impact on birth outcomes?
Hypothesis: Impact of early prenatal care is uneven
in the population
Need to be able to reach very high risk women
Impacts are washed out in a population average
20. I n c e n t i v e s i n c r e a s e d i n i t i a t i o n o f p r e n a t a l c a r e
b e f o r e w e e k 1 3 b y 3 5 % .
E f f e c t p e r s i s t e d f o r a t l e a s t o n e y e a r a f t e r t h e
i n c e n t i v e s e n d e d .
T e m p o r a r y i n c e n t i v e s h e l p p r o v i d e r s t o
o v e r c o m e i n e r t i a a n d c h a n g e c l i n i c a l p r a c t i c e
r o u t i n e s .
N e e d t o t a i l o r i n c e n t i v e s t o t a r g e t h i g h - r i s k
p o p u l a t i o n s .
Conclusions
21. Martin Sabignoso, National Coordinator of Plan Nacer and Humberto Silva, National Head of Strategic Planning of
Plan Nacer led the development and implementation of the experiment.
Luis Lopez Torres and Bettina Petrella from the Misiones Office of Plan Nacer oversaw the implementation of the
pilot facilitated access to provincial data, supported the authors in interpreting datasets and the provincial legal
framework and in carrying out the in-depth interviews.
Fernando Bazán Torres, Ramiro Florez Cruz, Santiago Garriga, Alfredo Palacios, Rafael Ramirez, Silvestre Rios
Centeno, and Adam Ross provided excellent assistance and project management support.
Alvaro Ocariz, Javier Minsky and the staff of the Information Technology unit at UEC provided valuable support in
identifying sources of data.
Sebastian Martinez, Luis Perez Campoy, Vanina Camporeale and Daniela Romero contributed to the initial design
of the pilot.
The Health Results Innovation Trust Fund (HRITF) and the Strategic Impact Evaluation Fund (SIEF) of the World
Bank generously funded the evaluation.
The opinions in the paper are of the authors alone and do not necessarily represent the opinions of the funder or
their affiliated institutions.
Acknowledgements