Incitants du côté de la demande et de l’offre au Nicaragua (réseau de protection sociale) Ferdinando Regalia Head of Social Policy & Economics UNICEF, South Africa Results Based Financing Workshop June 23 rd – 27 th, 2008, Kigali

2 Red de Protección Social (RPS)  Commencé en ~ 170,000 beneficiaires couverts au sommet du programme en 2004 (phase II)  Approche multisectiorelleMulti-sector approach: éducation, santé, nutrition  Programme d’assistance sociale basé sur les incitations (CCT) Transferts: ~ 1/5 de la consommation des ménages avant programme  Ciblé sur les pauvres (<US$1.10 / jour) Consommation médiane annuelle par personne avant le programme : US$ 320 (US$245)

3 RPS point de départ Matagalpa Madriz

4 Pourquoi des incitants du côté de la demande  Situation: les ménages pauvres consomment moins de services de santé préventifs que les non pauvres. Pourquoi?  Peut-être contraintes du côté de l’offre (bien que l’offre est médiocre de façon uniforme entre les localités)  …p-ê des contraintes du côté de la demande: Coûts directs et indirects élevés pour accéder aux services. Connaissance imperfaite du bénéfice économique à long terme d’un investissement dans la santé, etc..  Difficiles de distinguer les contributions des contraitnes offre/demande ex ante

5 Pourquoi les incitants du côté de la demande ? (2)  Solution proposée: quelques contraintes côté demande (ex connaissance imparfaite, externalités) justifiaient de conditions une assistance à certains comportements (RBF)  Intéressant: l’utilisation des services à augmenter plus fortement parmi les très pauvres que les non-pauvres. Alors que tous les ménages étaient exposés à une augmentation uniforme en termes d’accès et de qualité des services de santé  Challenges: en 1999, connaissance réduite sur comment mettre en place un CCT.

6 Why supply-side incentives?  Situation: Systemic capacity bottlenecks of MOH Unable to quickly expand services in remote localities  Proposed solution: service outsourcing to private providers through a competitive bidding process  Challenges: small market of private providers need to design incentives for health providers to develop efficient plans to rapidly expand coverage in underserved areas

7 Why supply-side incentives? (2)  RBF: providers to be paid based on the achievement of measurable and predetermined targets, verified by independent sources

8 What did RBF want to achieve?  D- and s-side incentives sought to increase: Utilization of preventive health services (children 0-5) Regular check ups (baseline: 70% among children < 3) Child growth and development monitoring (baseline: 60% among children < 3) including micronutrients and anti- parasites. Up-to-date vaccinations (baseline: 39% among children months) Utilization of maternal health services (Phase II). Pre-natal and post-partum control Parents’ attendance to health educational workshops Household sanitation, reproductive health, nutritional counseling

9  Planning stage: MOH opposed d-side incentives, fearing surge in workload Distribution of vaccines and other inputs, increasing referrals for curative services, etc. Government decided to go ahead anyway through SIF  Implementation stage: high involvement by local stakeholders Households’ targeting validation Local authorities’ support for logistics Randomized evaluation plans Coordination of supply side response Beneficiaries’ coordination through promoters Stakeholders’ buy-in: d-side incentives

10  MOH (central) aware of bottlenecks but resisted outsourcing Wage competition (potential exodus of health workers); no experience with contracting of services  Terms of the agreement between MOH and RPS team MOH responsible for providers’ selection, training and certification (with RPS team’s support in procurement) Additional budget allocated to MOH for supervision Providers obliged to feed the MIS of the MOH  Stronger buy–in by MOH regional offices Understood faster than the central MOH the potential gains in coverage to be achieved through outsourcing and RBF Stakeholders’ buy-in: s-side incentives

11  RPS socioeconomic survey administered to all HHs in (geographically) targeted localities  All HHs eligible for d-incentives if extreme poverty incidence high. Otherwise Proxy Means Test applied  Eligible HHs enrolled into roster. Mothers or primary care- givers entitled to receive bi-monthly transfers  All HHs’ members identified by a bar code. Transfer recipients identified by a special i.d. card with picture  Eligible HHs’ members mapped to health providers, payment agencies and schools  Pre-printed forms with names and bar-codes distributed by RPS team to health providers How d-incentives operate

12  Forms used by providers as planning tools to schedule all check ups with eligible HHs’ members. Information used by MOH to plan supply of inputs  HHs’ attendance recorded by health providers. Forms regularly collected by RPS team and information downloaded to RPS MIS  HHs’ record of compliance used to prepare payment orders. Two months lag between compliance updating and payments processing  Non compliance triggers suspension of transfers (10%). Repeated non compliance triggers expulsion (1%)  Spot checks of the compliance verification process How d-incentives operate (2)

13  One year renewable RB contracts for health providers  Contract’s final amount determined after a joint (RPS, provider) assessment of service coverage to: Validate, at the locality level, HHs’ demographic information collected through the RPS socioeconomic survey Identify the final “universe” of HHs a provider will be serving Enroll HHs with the provider and establish a baseline for the services to be provided  Contract’s final amount obtained by multiplying the number of people served (by age group) by the unit cost of the specific service provided to each age group  Providers are paid a per-HH fee for initial assessment How s-incentives operate

14  Upfront payment: 3% of the contract. The rest: bi- monthly or quarterly payments against the achievement of coverage targets by age groups  Targets: 93% - 95 % of active (i.e. receiving d-side transfers) beneficiaries by age group  If target missed, RPS MIS automatically stops payments to the provider for the period in question  Payments contingent upon RPS team’s verification of the coverage achieved (review of pre-printed forms)  External independent auditing of a representative random sample of records held by providers and households (twice a year). Penalties and termination How s-incentives operate (2)

15 Impact evaluation: selected results  Regular check ups (stronger impact for the poorest)

16 Impact evaluation: selected results (2)  Vaccination

17 Impact evaluation: selected results (3)  Stunting

18 Impact evaluation: selected results (4)  Increase in health service utilization persisted ten months after d-incentives discontinued Impact on % of children under 5 who had attended preventive growth monitoring during the previous six months Treatment Phase I Control Phase I/ Treatment Phase II Source: IFPRI (2005)

19  A package of d- and s-side incentives can increase utilization of preventive health care services Relative contribution unknown. Need to “unbundle the bundle”. D-side, S-side or both?  Implementation of d-side incentives is technically feasible even in low-income countries Fiscal sustainability considerations  Despite results, long term support for d- and s-side incentives in Nicaragua proved elusive D-side incentives controversial Cost-effectiveness of s-side incentives and outsourcing compared to alternatives, with or without d-side incentives A few final considerations