December 2009, Number 149 52049 A regular series of notes highlighting recent lessons emerging from the operational and analytical program of the World Bank`s Latin America and Caribbean Region. Extension of Health Services Coverage in El Salvador: The RHESSA Project Experience1 Introduction The rural areas presented an even bleaker picture: a 1998 For a variety of reasons, the governments of Central study revealed that children in the poorest quintile were America have struggled to provide basic healthcare three times more likely to be ill and had a 60 percent higher services to their rural and impoverished populations. rate of infant mortality than children in the highest quintile. The lack of incentives for healthcare personnel to reside in or even to travel to remote In addition, clients of the healthcare system expressed areas, along with the deep rural-urban deep dissatisfaction. For example, they pointed out: and rich-poor divides "Healthcare facilities operate only twice a week. have resulted in Consultation is only until noon. The doctor is not always poor coverage there. Waiting time is three hours on average. Only those and poor health that arrive by 8:00 get a consultation." Or they complained: indicators. Further, "The facility here is useless because there is no doctor or language and cultural barriers nurse, and it is only open two days a week until noon. and the lack of a budget for Waiting time is 3.5 hours average and there is a lack of transportation medication." in the rural departments In an effort to address the poor health indicators have added to the and the clients' complaints, to achieve equitable access complications in meeting the to healthcare, and to reach the goals established by needs of the poor. the Millennium Development Goals, the Salvadoran Government sought to extend essential healthcare In El Salvador, these failures were found primarily in the services to disadvantaged populations, especially Northern rural regions; however, after the earthquakes of mothers and children, the poor, and rural and indigenous 2001 damaged healthcare facilities, destroyed roads, and populations. To do so, the Ministry of Health embarked on added to the general poverty, these failures extended to an innovative approach to delivering services by pursuing the Central and near-Central regions. At that time, nearly two modalities of extension of coverage: 2 million people--one third of the population of 6.4 1. NGOs: Contracting out the provision of basic million--lacked basic access to healthcare. Preventable healthcare services to private non-governmental communicable and infectious diseases, malnutrition, organizations (NGOs); and diarrhea, and respiratory infections were common and disproportionately affected the vulnerable populations. 2. InstitutionalUnits:Creating internal contracting Life expectancy stabilized at a low of 69.4 years, maternal models, known as Institutional Units, within the mortality was 120 per 100,000 live births, and infant Ministry of Health with their own local public mortality was 35 per 1,000 live births, while the number of mobile providers. hospital beds barely reached 1.2 per 1,000 and only 11.7 doctors and 4.4 nurses served every 10,000 inhabitants. With the help of a World Bank loan, the Ministry focused 1. This note was prepared by the World Bank's team for the Hospital Reconstruction and Health Service Extension Project (RHESSA) composed of Team Leader Senior Economist (Health) Rafael Cortez, Research Assistant Consultant Isabella Bablumian, and Health Management Specialist Consultant Danilo Fernandez. 1 on: (1) solidifying the provision of health services to For units within the Ministry of Health, the performance remote and poor areas; (2) expanding coverage; and (3) contracts did not carry the same kind of legal responsibility. institutionalizing the program to assure its sustainability However, they included the same indicators and and governance for improved health results. Given the performance guidelines as the NGO contracts and emerging financial crisis, which could affect the size underwent monthly monitoring to assure compliance. and effectiveness of social budgets, the challenge is to The performance indicators evaluated monthly were also maintain this program and consolidate the improvements measured in the same way; the Ministry, however, could of the health indicators. not reinforce the indicators due to a lack of financing as a tool for performance enhancement. The performance Although the goal of extending coverage in the in this modality was more dependent on the Ministry's North had been articulated before 2001, the Ministry's ability to enhance its internal institutional capacity to administration was fragile and did not have a unified deliver services effectively. strategy to supervise and monitor the provision of services. The Ministry lacked the ability to contract, monitor and Results evaluate the work of the contractors, and to lead the sector As a result of these advances in extension of coverage, with a national priority-based health strategy. Previous the Ministry has succeed in increasing access to healthcare, programs, such as SALSA and "Promotores," were helpful and the beneficiary populations have experienced in extending coverage to poor people, but varied greatly important improvements in health. Overall, over 635,805 in the quality of services they provided­and they failed inhabitants, 75 percent of whom were living in extreme to provide widespread coverage. In addition, there was poverty, gained access to most basic essential healthcare no strong evidence that these programs represented a services in 104 municipalities and 591 cantons. Contracts sustainable solution to the health disparities. for extension of coverage (private sector and within the Ministry) were signed with 77 mobile teams; over How the Program Works US$ 8.4 million were invested into healthcare supplies, The Program included various mechanisms to improve medications, equipment, and staff training seminars, performance standards and to ensure that program goals among others. Each NGO team carried out an average were met. However, each of the two modalities needed of seven visits per month. The Ministry's mobile teams different incentives and tools to achieve a similar set of averaged over two visits per canton. goals. For the NGOs, legally-binding contracts between the Ministry and each mobile unit specified the minimum As a result of these gains in coverage, 95.3 percent of requirements to be fulfilled by each unit--such as children are now immunized with the six most essential services to be provided, geographic areas to be served, vaccines, and 95.5 percent receive a critical check-up and general guidelines for the health professional team. before turning 28 days old. Most pregnant women (76.6 Indicators served as monitoring tools to gauge whether percent) now receive at least five pre-natal checkups the goals met and the project objectives were achieved. to ensure better health for themselves and their future These included most critical health interventions and children. Most intermediate and health objectives were non-health performance measurements that could be not only fulfilled but surpassed their planned goals. quantified to provide a simple and easily implemented tool for monitoring and evaluation. To assess progress, Health the Ministry of Health and independent auditors audited The advances in coverage lead to many important monthly reports from the NGOs. improvements in the health of the beneficiary population. However, many of the improvements in health status Financing was also structured to reinforce compliance are not observable in the short-term--and past failures and enhance performance. First, providers billed the will continue to be reflected in the present. As coverage Ministry for services rendered plus or minus bonuses or expands, the positive incremental advances will also withholdings. The bonuses and withholdings depended accumulate. on whether and to what extent the goals were met. Second, fixed fee-for-service type payments shifted Children's Health: There were considerable partial risk from the contractor onto the providers. improvements in coverage for newborns and children Discretion regarding the use of funds created incentives under one year of age. to achieve higher performance standards and to provide more innovative and cost-effective services. At the same · 100 percent of children under one year are enrolled time, accountability for fulfilling minimum requirements in the program; assured that the quality of services and the responsiveness · over 70 percent enrolled before turning 28 days; to beneficiaries were not compromised. · 99.2 percent received complete vaccination coverage; and 2 THETWOMODALITIES NGOMobileTeams InstitutionalMobileTeams CoverageArea Northern Region Central and near-Central Regions Earthquake-affected poor areas with damaged Conditions Remote and poor areas lacking healthcare facilities. healthcare infrastructure. Contracting in of services to health units and signing ContractingMethod Contract out services to NGO providers. performance agreements with SIBASI-run mobile teams. Provide services to each community at least once a Provides services within the plan; visit once per month. RolesandResponsibilities month. Health promoter resides in each canton. Health promoter resides in each canton. BasicPackageofServices Basic health and nutrition services for children, mothers, and other at risk groups. Fixed fee for medical coverage, equipment, and Purchase of medical supplies and medications, transport, Financing human resource costs. and direct hiring and supervision of the medical team. Decision-making by the team. Risk of overspending Risk Ministry of Health responsible for services. by NGO. Monthly verification of indicators for the most Performance agreements supervised through MonitoringandEvaluation critical services. monitoring and evaluation reports. AdvantageforMinistryof Transfers risk to the mobile team providers and Infrastructure in place; direct control of activities. Health assures remote access for vulnerable populations. 1. Private sector cost-effective approach. 1. Less Costly. Strength 2. Strong human resource motivation 2. Direct control of the outcome. Weakness More expensive 1. Comparative tool for monitoring the differences. 2. Best allocation of resources possible at the time. Combination 3. Enhanced competition due to the insertion of public-private partnership. 4. Incentives for the Ministry of Health to develop both strong purchasing capacity and supervision capacity. · 97.8 percent received at least one form of medical cases of mortality during birth. The percentage of women attention. who received regular Pap smear tests for early detection of cervical cancer also increased to 79 percent in the NGO Some improvements were also made in child nutrition modality and over 90 percent in the Institutional modality. and weight control: 99.5 percent of children were evaluated for those indicators. Malnutrition (moderate or Assuring Sustainability: Institutional Strengthening severe) has diminished to 15.2 percent of the children's and Financial Support population. The infant mortality rate also improved: for One of the most challenging components of externally areas attended by NGOs there were 16.1 deaths reported financed social projects is the difficulty in sustaining the per 1,000, and 13.3 deaths 1,000 in the areas attended by project activities once the outside support ends. The the Institutional Units. These data represent a significant institutionalization of the project is a critical component improvement from the 22 per 1,000 reported by UNICEF to assure that the program becomes entrenched in in 2006 and are lower than the 17 per 1,000 Millennium Development Goal for 2015. Mortality from diarrhea and respiratory infections fell to zero (in the NGO areas) and 2.02 per 1,000 persons (in the Institutional areas). Women's Health: Increased coverage reduced the proportion of unattended births by 25 percentage points. At the end of 2008, 86.3 percent of pregnancies were attended by qualified professionals. There were also some increases in the percentage of women who underwent an adequate number of prenatal visits; 52 percent of those who subscribed early in their pregnancies complied with the five and up requirement. the country's health system and continues despite political and administration changes. In El Salvador, the Postnatal visits increased considerably to 89 percent of Ministerial Accord No. 1000 made official the process of women registered. Additionally, there were no recorded institutionalization of the extension of coverage, while the 3 OBJECTIVESANDRESULTS Objective ProgramGoals BaselineIndicators Results(asof2009) Intermediate 77 mobile teams, 635,805 persons covered in 104 Extend coverage 0 beneficiaries Goals municipalities and 591 cantons. NGO teams extended services to 282,353 inhabitants in the Extend coverage in the Northern region. 0 beneficiaries 61 municipalities in Northern region. Extend coverage in the Central, near-Central, 0 beneficiaries Coverage extended to 316,821 inhabitants. and Eastern regions Increase vaccination of children under 2 years FinalObjectives 76.6 % vaccinations 95.35 % vaccinations of age by 20% Increase coverage of pre-natal visits by 20% 76.6 % received at least 5 78.1% receive at least 5. Increase number of per capita contracts in Seven contracts per NGO and 1.57 contracts per mobile 0 contracts communities by 50% team. 74.6% of children under 5 Promote child growth sessions: by 90% 97.4% of children under 5 in cantons enrolled. enrolled health; close to 98 percent also indicated an adequate supply of medicines available; and between 95.5 percent and 97.6 percent of beneficiaries indicated that their health needs were met by the extension coverage teams. Additionally, respondents mentioned substantial drops in out-of-pocket spending on healthcare and reduced average time of travel to the health units by about 15 minutes. Conclusion The successful extension of coverage through the two modalities and institutional strengthening is encouraging creation of the unit within the structure of the Ministry of for progress in overcoming one of Central America's Health made it operational. most severe challenges in healthcare provision. The strategy of public-private partnerships and institutional The Ministry of Health was eager to secure financial enhancements provides an equitable and cost-effective sustainability in the early stages of the project. The use of limited-resources to meet the basic healthcare Salvadoran Government and international donors were needs of the most vulnerable. In the future, the Salvadoran impressed with the Program's success and impressive Government will face the challenge of internalizing the achievements and supported its continuance. To that end, provision of services to remote groups into the current the Government budgeted US$4.3 million to continue public health system. The Government will also require the services through 2009. The Ministry also obtained creating an effective surveillance and information system another US$2.9 million to continue with the process of to strengthen its management of decentralized health institutionalization. This support is critical in ensuring that units. Finally, it will need to maintain and enhance the the program continues and that recent gains are not lost. mobile health units' strategy, which has proven to be an effective instrument and a sustainable solution in the Beneficiary Satisfaction and Comments context of economic crisis and increasing health needs. In addition to meeting the objective goals, the Project boasts a high level of beneficiary satisfaction. Between 98.4 percent and 100 percent of beneficiaries considered the services as valuable for improving their communities' "en breve" is produced by the Knowledge and Learning Team of the Operations Services Department of the Latin America and the Caribbean Region of the World Bank - http://www.worldbank.org/lac