Improving Health Outcomes in Mesoamerica
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The Salud Mesoamérica Initiative (SMI) is a public-private partnership between the Bill & Melinda Gates Foundation (BMGF), the Carlos Slim Foundation, the Government of Spain, the Inter-American Development Bank (IDB), the countries of Central America and the State of Chiapas in Mexico. SMI works to reduce maternal and health inequalities through a results-based financing model, aligned with priorities established by the governments of the region. Among the poor in Mesoamerica, only 5 out of every 10 pregnant women are attended during childbirth by skilled birth personnel and the mortality rate among children in poverty is twice that of the national average.
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Improving Health Outcomes in Mesoamerica
- 1. Success beyond numbers: The Salud Mesoamerica Initiative’s results- based financing approach to improve health services for the poorest in Mesoamerica World Bank BBL Presentation Social Protection and Health Division- Inter American Development Bank Emma Margarita Iriarte, Executive Secretary of SMI
- 2. What does SMI aim to change? Only 1 of every 2 pregnant women in the poorest 20% gives birth assisted by skilled personnel Twice as many children <5 years of age in the poor population die compared to the regional average A 5-year-old child from the poorest 20% is 6cm shorter than a child from the wealthiest 20% x2
- 3. What does SMI aim to change? SMI areas: baseline situation (2012) – child health Chiapas El Salvador Guatemala Honduras Nicaragua Panama (%) Population Health Metrics, 2015: Salud Mesoamérica 2015 Initiative: design, implementation, and baseline findings
- 4. What does SMI aim to change? SMI areas: baseline coverage (2012) – women’s health Modern contraceptive prevalence rate Institutional births by skilled personnel (%) * Institutional births by skilled personnel not measured at baseline Population Health Metrics, 2015: Salud Mesoamérica 2015 Initiative: design, implementation, and baseline findings
- 5. What does SMI aim to change? SMI areas: baseline situation (2012) – quality of care * Information on equipment and inputs is not available Health facilities with continuous availability of equipment and inputs for emergency neonatal and obstetric care Neonates with complications (low birth weight, prematurity, asphyxia, sepsis) treated according to the norms Women with obstetric complications (pre-eclampsia, eclampsia, sepsis, hemorrhage) treated according to the norms (%)
- 6. What does SMI aim to change? SMI areas: Crude vs Effective Coverage of Measles Immunization in Mexico and Nicaragua Chiapas, Mexico Nicaragua Citation: Colson KE, Zúñiga-Brenes P, Ríos-Zertuche D, Conde-Glez CJ, Gagnier MC, Palmisano E, et al. (2015) Comparative Estimates of Crude and Effective Coverage of Measles Immunization in Low-Resource Settings: Findings from Salud Mesoamérica 2015. PLoS ONE 10(7): e0130697. doi:10.1371/journal.pone.0130697
- 7. What is SMI? SMI: Public-Private Partnership – Collective Impact Initiative •Bill & Melinda Gates Foundation •Carlos Slim Foundation •Government of Spain •8 Mesoamerican Countries •IDB Grants: US$ 114m Domestic Funding: US$ 55m Objective: Reduce inequities in maternal, neonatal, child, and adolescent health in 1.8 million women and children
- 8. What makes SMI different? From… To… • Beneficiaries and Donors • Financing inputs: Buying micronutrients • Thinking about who and what to support • Risk intolerance and resistance to change • Assuming we made a difference • Partners and joint-investors • Buying Results: Reducing Anemia • Focusing on leverage points and removing bottlenecks to reach targets • Taking smart risks, learn from failures and adapt • Verifying we met our goal
- 9. SMI aims to create value for the entire field Porter and Kramer, Philanthropist’s New Agenda: Creating Value. How can we do development better? How can we do development better?
- 10. Target the poorest 20% of the population Results Based Financing (RBF) model – Incentive at national level SMI approach: critical features
- 11. Evidenced based interventions and systemic approach Supply and Demand side interventions Context specific and action-oriented technical assistance Independent measurement of performance at outcome level Regional dimension and benchmarking SMI approach: critical features
- 12. Based on the General Framework, countries built their Performance Framework with 8-12 indicators per phase On average, each Performance Framework has a total of 24 indicators Results and Performance Frameworks M&E Indicators SMI Indicators ~50 indicators Performance Framework Performance Tranche ~24 indicators Regional Monitoring & Benchmarking Linked to Performance Incentive
- 13. Selection of performance indicators 90% of health facilities with permanent availability of family planning methods Unmet need for contraceptio n decreases 5% PP Unmet need for contraception decreases 10% PP permanent availability of family planning methods unmet need for contraception Targets set for all indicators Process indicators Coverage & Quality indicators Coverage & Quality indicators 18m targets 36m targets 54m targets 18 months 36 months 54 months Operation 1 Operation 2 Operation 3 100 50 0 0 months
- 14. What do countries commit to? Key Performance Indicator Baseline 1st Operation Targets 2nd & 3rd Operation Targets Primary Health Centers with permanent availability of medicines and inputs for obstetric and neonatal emergencies 62.5% 80% Primary Health Centers with permanent availability of medicines and inputs for the treatment of diarrhea and pneumonia in children under 5 0% 80% Institutional births by skilled personnel 63.9% +12 PP Management of obstetric complications 11% + 40 PP Children less than 5 years that received oral rehydration salts and zinc during the last episode of diarrhea 0% +25 PP Anemia in children 6-23 months 35.3% - 15 PP Example: Honduras (selected targets)
- 15. How did SMI set and negotiate targets? Trend of national health indicators and evidence on impact of interventions Literature review, international experiences Economic model based on cost-benefit analysis Power calculations Expert consultations and art Set individually with each country
- 16. Target negotiation • Ambitious but achievable • Commitment and support from authorities • No baseline? – Absolute changes (gold standard): for example, above 85% – Relative changes: 20 percentage points above the baseline
- 17. SMI Scoring system ‘All or nothing’ rule focuses efforts on all targets, but makes receiving the performance award more challenging
- 18. SMI independent performance measurement Final Evaluation Final Evaluation 1st Operation (18-24 months) 2nd Operation (18-24 months) 3rd Operation (18-24 months) First verification of targets First verification of targets Second verification of targets Second verification of targets Third verification of targets Third verification of targets *Health Facilities and Population Based Surveys We are here. In most countries, the second operation is in progress.
- 19. Role of measurement in SMI • Setting and verifying targets – Monetary incentive (PT) • Comparable data between countries – Reputational Incentive • Generate data for evidence-based policy dialogue and program design • Program monitoring and course correction • Learning about effectiveness of the model
- 20. …but is just measurement enough? • Need for technical assistance on how to implement evidence-based interventions – Especially in the hardest-to-reach areas: platforms, new mechanisms to deliver services – Systemically and at-scale – Need to create evidence-based culture – Management and organizational issues • Funding to test new interventions/innovations – Scarcity of non-earmarked funds
- 21. *PPT Broach Branch Associates July 2015; SMI Donors Committee SMI systems-based intervention approach Accountability • Improved maternal, newborn, child and adolescent health • Enhanced Equity • Healthy Communities ResultsDrivers & Enablers
- 23. Performance indictors linked to changes in national norms and protocols (1st Operation) Country Policy Dialogue Indicator – Updated Norm Status Belize • Quality of reproductive and child health services • Establishment of a community platform of services Completed El Salvador • Micronutrient powders to reduce anemia and zinc for treatment of diarrhea Completed Honduras • Common childhood diseases • Micronutrient powders approved Completed Nicaragua • Community platform and nutrition interventions Completed Panama • Inclusion of zinc for diarrhea treatment Completed
- 24. Measurement and Monitoring through:
- 25. SMI first round of results (18-24 months) Very sizeable changes in the supply of essential health care in a short period in all countries 69% of the 83 negotiated targets met in 8 countries Costa Rica, El Salvador, Honduras, Nicaragua and Panama received the performance tranche (PT) Belize, Chiapas and Guatemala mastered an impressive progress but fell short of the cut off to receive the PT Chiapas, Guatemala implemented an improvement plan, with their own resources, were re-measured and achieved all the targets
- 26. Honduras: success stories Baseline(%) 18-Month(%) Indicator data 0 50 Resuscitation bag for adults 83,3 100 Neonatal resuscitation bag 100 100 MVA kit 66,7 100 Stethoscope 66,7 100 Sphygmomanometer 83,3 100 Pinard stethoscope/portable doppler 100 100 Oxygen tank 83,3 100 Autoclave/dry heat sterilizer 66,7 83,3 Pediatric/neonatal stethoscope 0 83,3 Laryngoscope 100 83,3 Anesthesia kit 66,7 66,7 Uterotonics 1 100 100 Tetracycline eye ointment 16,7 100 Saline wash 66,7 100 Saline solution or Ringer's lactate 83,3 100 Magnesium sulfate 100 100 Anti-hypertensives 2 100 100 Naloxone hydrochloride 83,3 100 Furosemide 100 100 Phenobarbital sodium 100 100 Diazepam 100 100 Dextrose 66,7 100 Dexabethasone/ betamethasone 3 66,7 100 Sodium bicarbonate 100 100 Antibiotics 4 100 100 Adrenaline 100 100 Atropine/epinephrine 100 100 Health facilities with availability of supplies, medicines and equipment for neonatal and obstetric emergencies in hospitals Equipment Pharmacy inputs
- 27. Chiapas: success stories Child care Antenatal and postpartum care Emergency obstetric and neonatal care Delivery and newborn care Family Planning *All percentages reflect the Performance Improvement Plan Measurement (PIPM) definitions with no stock-out
- 28. Belize: success stories Health facilities with availability of equipment for child care (“heat map”)
- 29. Taking stock of SMI: voices from the countries* *In depth interviews with a sample of national and district level leaders of the Ministries of Health (independent evaluation by Rena Eichler and Susan Gigli). Positive Aspects • Overall feedback is highly positive • Management by results is new and perceived as catalytic and creates new partnerships • SMI is enhancing Know-How • New evidence based strategies and results oriented interventions are being introduced. • Supply systems are being strengthened Challenging Aspects • Short Timelines • Some targets were too ambitious • Construction of some indicators could be improved • Initial incomplete understanding of what needed to happen to achieve targets • Frustration with the country’s own systems and their capacity to move quickly
- 30. Moving forward Next set of targets are much harder: coverage and quality of interventions and selected outcomes (population-based results) Addressing funding gaps Continue facilitating technical assistance and collective learning and innovation. Sustainability: how to maximize the likelihood that system enhancing changes will be sustained?
Editor's Notes
- We have evidence about what works to save lives in maternal and child, however, unnecessarily people are dying every day in one of the most unequal region of the world – Mesoamerica. Many of the inequalities seen here are hidden by improving national averages. The numbers here are a small sample of the inequalities faced by the poorest 20%.
- In 2012-2013, SMI performed a baseline study in the poorest areas of each country, where the program would be working. Everyone expected the poor to be worse off, but many were shocked by how much worse off these populations are. Vaccination, something the region is very proud of and worked hard to achieve national averages over 85%, in the poorest regions, there is still a lot to go (see Panama 9.9% and Guatemala 12.5%). Anemia – directly related to cogitative development and stunting – a risk factor for diminished survival, childhood and adult health, learning capacity and productivity – complete with levels found in some of the most impoverished areas of Africa (Ethiopia= 64%) In Panama, one of the fastest growing economies and home of the Panama Canal, just 2 hours from the capital, 3 of 4 children are anemia and 1 of 2 are stunted. Similar trends are seen in Guatemala.
- Women’s health shows how international aid efforts in the last 20 years (Mainly USAID) have made lasting impacts – even in the poorest populations – However in Chiapas, Guatemala and Panama coverage of basic interventions like institutional birth and modern family planning rates are extremely low. When women were asked why they didn’t give birth in the hospital in SMI barriers analysis, many listed the cost to travel to the health center and that they had no one to watch their children. Cultural issues were also a concern. Both of these demand side barriers have been worked into SMI Operations.
- As you could see in the slide beforehand, countries like Honduras, Nicaragua and El Salvador had intuitional birthrates over 80%. The data presented here focuses on the next frontier – quality of health care. According to the SMI baseline survey, in the targeted areas, less than 15% of health centers had the basic equipment needed for a quality delivery – like oxytocin, a lifesaving uterotonic – and less than 10% of all neonatal and obstetric emergencies were treated according to the norm. If 100 women showed up for a birth, less than 10 of them received the quality of care they deserved.
- Dry Blood Sample of Seroprevalence of measles vaccine allows us to see the difference in crude vs. effective coverage is alarming. Due to problems in cold chains, some of the children vaccinated are not protected from these preventable diseases. Abstract from paper: Timely and accurate measurement of population protection against measles is critical for decision-making and prevention of outbreaks. However, little is known about how survey based estimates of immunization (crude coverage) compare to the seroprevalence of antibodies (effective coverage), particularly in low-resource settings. In poor areas of Mexico and Nicaragua, we used household surveys to gather information on measles immunization from child health cards and caregiver recall. We also collected dried blood spots (DBS) from children aged 12 to 23 months to compare crude and effective coverage of measles immunization. We used survey-weighted logistic regression to identify individual, maternal, household, community, and health facility characteristics that predict gaps between crude coverage and effective coverage. We found that crude coverage was significantly higher than effective coverage (83% versus 68% in Mexico; 85% versus 50% in Nicaragua). A large proportion of children (19% in Mexico; 43% in Nicaragua) had health card documentation of measles immunization but lacked antibodies. These discrepancies varied from 0% to 100% across municipalities in each country. In multivariate analyses, card-positive children in Mexico were more likely to lack antibodies if they resided in urban areas or the jurisdiction of De Los Llanos. In contrast, card-positive children in Nicaragua were more likely to lack antibodies if they resided in rural areas or the North Atlantic region, had low weight-for-age, or attended health facilities with a greater number of refrigerators. Findings highlight that reliance on child health cards to measure population protection against measles is unwise. We call for the evaluation of immunization programs using serological methods, especially in poor areas where the cold chain is likely to be compromised. Identification of within-country variation in effective coverage of measles immunization will allow researchers and public health professionals to address challenges in current immunization programs.
- Based on the situation described in the slides above, SMI was created to health reduce the health equity gap. SMI is a hybrid program, combining best practices and promising interventions, through a combination of results-based funding; a creation of a partnership with public- the government of Spain and -private donors – the two richest men in the world, countries, and the IDB; evidence-based interventions balanced by innovations supported through learning through success and failures; demand-based technical assistance; and pro-poor focus – countries agree to only work in the 20% poorest part of the population.
- This left us with the challenge of how to catalyze the uptake of health innovations for the poor within and between countries at scale to reduce the health equity gap. This was the question posed by this partnership, and it meant we couldn’t “do business as usual” Based on our calculations – over the lifetime of the Initiative we have the opportunity to prevent over 15,000 maternal and child deaths in the areas we work (LiST Model) – the challenge we faced was how were we going to scale up these interventions quickly? To make this change, this slide represents of the key transitions at work within the program – that make us different
- Additionally, SMI seeks to create value for the entire field, not only studying if targets are met, but learning if the model allows for a new model with increased effectiveness and efficiency to meet targets – seeking to contribute to advancing the state of knowledge and practice in the field – according to HBR, this makes every dollar spent in the partnership more productive Resource link: https://hbr.org/1999/11/philanthropys-new-agenda-creating-value
- Pro-poor focus 3 sets of funding: IT, CP, PT Note that the funding for country operations is less than 2% of the annual health budget. This type of funding is “catalytic” in that it sets of a series of changes to meet targets, but doesn’t necessarily finance them. The cost of reaching targets the countries commit to is much higher
- SMI created a catalogue of indicators which would be measured in all countries – SMI General Results Framework Based on the General Framework, countries built their Performance Framework with 8-12 indicators per phase First Operation: Process Indicators Second and Third Operation: Coverage and Quality of Care Indicators On average, each Performance Framework has a total of 24 indicators All countries are measured by the General Results Framework for monitoring purposes Resource: Folder 2 and Folder 4
- This slide is an example of the type of goals countries commit to at the outcome level. SMI is implemented through 3 phases of country operations, each with 10-12 performance targets verified through external surveys. Targets get harder with each phase. The first phase focused on necessary policy and operational guideline changes, supply and demand side inputs and processes. The 2nd on coverage and quality and the 3rd on Effective Coverage – like reduction of anemia and seroconversion of the measles vaccine NOTE: the last two targets area actually for the 3rd operation in Honduras
- Target setting tools helped to set “ambitious but achievable” targets Tools allowed for commitment and support from authorities to achieve targets Tools contributed to removing motivational and aspirational aspects in target setting Given that the majority of the countries did not have baseline data when they were establishing targets, targets were set two ways: Absolute Changes (Gold Standard) Above 85% Relative Changes Change in 20 Percentage points relative to baseline
- Note- I added here a bar for where funding is needed for consideration…
- SMI uses three main types of PD: fiscal, technical and operational. IDB is a trusted partner in region with more then 50 years of PD experience
- Some examples of Technical and Operational PD In some countries, changes to national norms and protocols were necessary. In 5 countries, changes were performance indicators, meaning they had to be completed in record time (usually this process takes 4-5 years) and the documents underwent external verification to ensure they met evidence-based criteria
- “A System for Rapid Learning and Improvement” refers to a set of structures and processes that help providers of health care at every level of the system (national, regional and local) to: Understand their current performance; Set aims for improvement; Build will for change; Access the latest and best evidence-based knowledge; and Test new innovations to rapidly enhance outcomes. Importantly, a system of this kind seeks to avoid the pitfalls of typical learning activities which are often characterized by: Vague aims; Old data; Static, underused knowledge repositories; and Didactic training programs that put providers in a passive position.
- 1Baseline measured oxytocin or ergometrine, while 18-months measured these two or ergobasine 2Hydralazine, hydralazine hydrochloride, alphamethyl dopa, propanolol, nifedipine 3At baseline, only dexamethasone is measured; at follow up, betamethasone is also measured. Requirement for one of these two drugs only applies to follow-up 4Amoxicillin, ampicillin, amikacin sulfate, penicillin G, clindamycin, cephalexin, dicloxicillin, doxycycline, gentamicin, metronidazole
- Here is should be noted that Chiapas did not pass the first round (green) although they made great progress from baseline (yellow). They created a Performance Improvement Plan, and without additional funding, were measured 6 months later to revel that had met 100% of their targets
- Here we should note that Belize did not pass and receive the prize, but still made vast improvements as illustrated here
- 4 key issues moving forward – key issue is finding funding for the 3rd operations, were we expect changes in effective coverage indicators and adequate time to see sustainable changes in the countries’ health systems