To improve the management and delivery of health services to its citizens, and address equity, efficiency, and access gaps in its public health sector, the Government of Nicaragua engaged in an exchange with Argentina. They learned new payment mechanisms that will help improve the quality of preventative care, and provision of basic health care to the poorest and most vulnerable.

Challenge

The Government of Nicaragua sought to improve the management and delivery of basic health care to its poor and vulnerable, in an effort to address issues of equity, efficiency, and gaps in access to such services.  As the steward of the health care system, the Ministry of Health (MINSA) introduced new payment mechanisms and plans to help facilitate universal and accessible health care across the country. In 2008, MINSA revised its National Health Development Plan to include a Community and Family Health Model (MOSAFC) to focus on providing universal access, and it adopted a preventative approach to health care. A planned payment system sought to allocate resources directly to local communities through monitoring and rewarding community based health achievements, with the intention of insuring that basic health care reached all levels. However, the government lacked financial and human resources, and adequate internal capacity to effectively implement MOSAFC.

Solution

Nicaragua requested Bank support for an exchange with Argentina, whose public health system had successfully instituted a capitation payment and results-based payment system that includes performance agreements, auditing processes, and monitoring and evaluation schemes.  This was done through activities such as the Provincial Maternal-Child Health Improvement Project (Plan Nacer), which had been in operation for over 10 years and was viewed as a best practice in the region.

The exchange had two primary components:

• Expert Visit: A team of senior officials from Argentina, including representatives of Plan Nacer, FESP, and, Healthy Municipalities travelled to Managua to meet with senior officials from MINSA. The visit, from September 4-6, 2012, featured an institutional strengthening workshop.  The Argentines shared lessons and best practices on implementing capitation and output-based financial processes and tools, essential public health functions, monitoring and evaluation, implementation strategies and concurrent audits. In addition, they made available relevant documents of Plan Nacer and FESP.
• Study Visit:  In a follow-up, six high level technical representatives of MINSA had a study visit to Argentina from November 3-9, 2012. While there,  the Nicaraguan representatives visited a range of institutions in Buenos Aires, and met with representatives of the Ministry of Health, FESP, Plan Nacer, and, Unidad de Financiamiento Internacional de Salud (UFIS). They also visited the Province of Mendoza, and held other meetings with the Situation Room in Maipu Province, the Dr. Ramón Carrillo Hospital in Las Heras, Ramón Sardá Hospital, the Provincial Government, and the Program of Healthy Municipalities.

Results

The exchange provided Nicaragua with practical insights to improve health care and delivery, especially to communities with the poorest and most vulnerable citizens. Specifically it:

• Facilitated the creation of formal and informal networks of policymakers from the two countries for future formal and informal exchanges. In 2013, both countries committed to signing an umbrella agreement for future collaboration. Although the agreement was never officially signed, collaboration has continued.
• Enhanced the institutional capacity of the Nicaraguan government to deliver essential public health functions, by showing participants first-hand accounts of the successes and challenges of instituting an effective health care payment system across its local municipalities. This in turn improved access and the quality of preventive health care and promoted health and nutrition services among the vulnerable.
• Increased the capacity of multiple government agencies, as principles from the systems observed have helped to modernize the health care system as well as that of the National Statistics Office.
• Enhanced knowledge and skill as the Nicaraguans learned about modernizing their payment systems for capitation and results-based health services, while also learning about community-led innovative initiatives in remote areas, such as mobile brigades, maternity homes, and community health practices.

The Nicaraguan delegation requested to buy relevant software for updating data systems and to strengthen appropriate monitoring and evaluation systems. They have drafted proposals to modernize and update systems in MINSA. In addition Nicaragua agreed to replicate a study done in Argentina on the burden of disease, as part of its broader health strategic planning. 

Lessons Learned

• As observed in this exchange, small delegations allow for in-depth discussions. For instance, on the second day of the workshop two smaller focused groups, one on capitation payments and the other on institutional strengthening facilitated in-depth discussion and analysis.
• In addition to group discussions, supplementary documentation from best practice models – such as shared by Plan Nacer and FESP – further enhance insights.
• The delineation of the exchange into two phases allowed for effective knowledge scaffolding. The first was a workshop which included making available preparatory documents for the second hands on phase which allowed participants to see the theory in practice.
• Intense field visits supported by a variety of case studies proved effective for broadening knowledge.

World Bank Group Contribution

The Bank’s primary contribution was the facilitation of the exchange and providing financial support. In addition, the Bank has collated and published the relevant Plan Nacer and FESP documents as a toolkit to share with other countries. 

Partner

Senior officials from the Ministry of Health in Argentina and from national and provincial health agencies provided knowledge for this exchange. This included the Ministry of Health, Plan Nacer, the Essential Public Health Functions and Programs Project (FESP), Unidad de Financiamiento Internacional de Salud (UFIS), the Province of Mendoza, Situation Room, Dr. Ramón Carrillo Hospital, Ramón Sardá Hospital, and the Program of Healthy Municipalities. Individuals representing these partners included:

• Coordinator, Plan Nacer
• Manager, Medical Audits, Plan Nacer
• Coordinator, Essential Public Health Functions and Programs Project (FESP)
• Program Coordinator, Healthy Municipalities
• Vice Minister of Health, Argentine Ministry of Health
• Ministry of Health, Province of Mendoza

Moving Forward

Both countries agreed to establish mechanisms for further discussion and collaboration and to sign an umbrella agreement to that effect after the completion of the exchange. Although the agreement signing is still only a possibility, ongoing collaboration has continued.

Beneficiaries/Participants

The key beneficiary of the exchange was the Ministry of Health in Nicaragua (MINSA). Nicaraguan participants included:

• Project Coordinator, Improving Community and Family Health Care Services
• Director, Planning Area, Ministry of Health
• Financial Coordinator and Technician, MINSA
• Chief of Statistics, national Statistics Officer
• Chiefs of Local Level Offices (SILAIS)

Learn More

• Nicaragua Ministry of Health website: http://www.minsa.gob.ni/  (in Spanish)
• World Bank Approves US$21 Million to Improve Health Care Services in Nicaragua: http://www.worldbank.org/en/news/press-release/2010/12/07/world-bank-approves-us21-million-improve-health-care-services-nicaragua