Results based aid for universal health coverage in poor and indigenous communities: Impact evaluation of the Salud Mesoamérica Initiative

Abstract

Mesoamérica, a region spanning Southern Mexico to Panama, is pursuing a Universal Health Coverage (UHC) agenda to overcome significant health and economic disparities. UHC entails both ensuring financial protection from health expenditures and providing access to quality services. Beginning in 2011, eight Mesoamerican countries joined the Salud Mesoamérica Initiative (SMI), a results-based aid (RBA) program aiming to reduce maternal and child health disparities. Countries and SMI donors negotiated financially incentivized targets for improving process and outcome measures in marginalized regions. Integral to SMI is an independent evaluation, involving thousands of health facility and household surveys over several years, used for this dissertation. It first assesses baseline levels of financial protection in SMI target populations of six countries, finding high levels of out-of-pocket payments (particularly on prescription drugs) and over 20% of households forgoing care due to cost. Next, it evaluates the impact of SMI’s first two phases on financial protection in four countries, finding significant improvements in Honduras (mediated by use of the public over private sector and less self-reported illness), but null or mixed results elsewhere. Finally, it evaluates SMI’s impact on prenatal care in Honduras, finding that SMI improved the timing and quality of care recorded in medical records, but not according to women’s own recall. Collectively, these findings give early indications that SMI RBA model improved select UHC indicators in certain settings, but not others. It implores the need for quantitative and qualitative work to evaluate if SMI can achieve population-level health improvements and understand the contextual factors leading to success in some settings and failure in others.