A summary of the voucher panel at Global Health Council’s annual meeting in DC May 27th. Cross posted from Jaspal’s original post on Global Health Ideas…

As with the last post, I’m copying the description of the session I just attended - Vouchers for Health (Session C3) - from the conference website:

Presenters Discuss: the potential of competitive vouchers in increasing access to priority services for currently underserved populations (Nicaragua); how subsidized, targeted vouchers can achieve the goal of improving health of poor women and children, elements that improve access to high quality health care services, how targeted voucher subsidies help meet the goal of contributing to development of a national social health insurance system that is accessible, affordable and acceptable (Kenya); a nationwide, high transaction distribution project for insecticide treated nets (ITNs) that has given rise to the application of technologies in the use of a relational database as a means to track each voucher transaction, ensuring security and traceability, providing spatial analysis using GPS coordinates, leveraging data from this project to others by providing a central data repository to government, and exploring SMS and mobile phones for automating voucher transactions and gathering patient information (Tanzania); and how poor pregnant women were selected for vouchers jointly by field workers and community support group members, how the institutionalization process for the voucher scheme was implemented, and how the health facilities were strengthened to provide quality maternal health care (Bangladesh).

Why should we care about voucher schemes? Three reasons from where I sit. These schemes provide:

1. An attractive model for extending the reach of services without significant infrastructural investment
2. Incentives for competition to improve the quality of service delivery
3. A mechanism for reducing financial barriers for the poor

Despite this promise, my experience over the last few years - including stumbling through a poster presentation about vouchers in Uganda for Ben at APHA in Boston a couple years back - has taught me that the concept tends to be elusive to “outsiders”. The World Bank’s Private Sector Development Blog has a concise overview of output-based aid for those that aren’t familiar. I won’t try to explain myself, since I’ll probably make some errors.

This session brought together diversity in geography - the talks covered Latin America, Africa, and Asia - and in services - anti-malarial bednets, safe motherhood, family planning, STI prevention and treatment. What was most interesting to me then was not the details of any specific program, but what we might be able to learn from having these different experts in the same room.

So what were the common themes?

1. Vouchers work. Nicaragua saw increases in service utilization, condom utilization, family planning uptake, and KAP. Much of this across different subgroup analyses - age, level of sexual activity, type of residence. The others similarly all saw positive gains in what they were trying to achieve.
2. Institutions matter. In Tanzania, the market is being flooded with free ITNs (possibly LLINs) under a new policy to achieve universal coverage - the fate of the 7000 bednet retailers under the Tanzania National Voucher Scheme (TNVS) is unknown. In Kenya, Nairobi and Kiambu saw better results for the voucher scheme because of existing infrastructure. Nairobi actually had provided more voucher-based services than vouchers sold in Nairobi because of women coming in from outlying areas. Tanzania benefits from a manufacturing base that can produce ITNs and a system that encourages people to pay for a portion of their health care.
3. The system will be gamed. The much higher reimbursement for providers of C-sections than vaginal deliveries has led in some cases to higher rates of C-sections than is necessary. April Harding who was moderating said that multiple schemes have been used/proposed for dealing with this, including capitation (e.g. for 100 women, X% will be reimbursed for C-sections). Fraud is also a problem. While nobody discussed incidences of counterfeiting, the Tanzania program has taken big steps to prevent counterfeiting, including watermarks, microprinting, and a bar code. The bigger issue with fraud is related to ineligible participants obtaining and using vouchers intended for other populations, whether by income or geography. Which leads us to the next point…
4. Equitable distribution is hard. Ineligible participants seem to be a problem with all these programs. In Bangladesh they responded by bypassing governmental decisions about who would get vouchers and relied on CSGs (community support groups) to make the decisions. Another trend is that those who are more poor tend to utilize vouchers less - it is unclear if this due to cost, education, and interaction among the two, or something we’re not thinking about.
5. Understanding redemption is complicated. This was my one question. In both Tanzania and Kenya - the others didn’t present these numbers or I didn’t catch them - the rate of redemption (number of people receiving services under the voucher scheme divided by the total number of vouchers distributed) - was around 80%. After I asked the question and before the panelists responded, my neighbors said that: (1) 80% is pretty good, and (2) the Tanzanians unlike the Kenyans don’t pay for their vouchers until they use them. In Tanzania then, the reasons are grounded speculations: perceived value of the ITNs, access, cost. In Kenya, the majority of the outstanding 20% is due to accounting. The real utilization is expected to be much higher since the cutoff for the evaluation excluded women who had received vouchers, but had not yet delivered (safe motherhood program). Still a minor portion of this is due to women who are unable to deliver at contracted facilities due to a lack of transportation or the timing of the pregnancy.

Update from a blog that I occasionally write for and follow often…

The Technology, Health and Development blog (THD Blog) formerly hosted at http://thdblog.wordpress.com has moved and changed names to this current site - Global Health Ideas (http://globalhealthideas.org). Partly because of increased attention and scope we decided it was time for a more permanent home that would also allow us to do more. We are still going to be blogging about global health solutions, innovative projects and the use of technology and you can continue to reach any of us at thdblog AT gmail DOT com. All of our old posts will remain on the old site  and also can be found on this site. Please bear with us over the coming weeks as we sort through various bugs and coding errors.

• You can subscribe to our blog feed from the following link: http://globalhealthideas.org/?feed=rss
  
• And for those on twitter you can find Jaspal at: http://twitter.com/jaspaldesign

The online chat last week (full transcript .txt) hosted by Abt Associates covered a wide range of topics in OBA: utilization, fraud control, quality assurance, targeting, demand versus supply side programming, clinic management of medical supplies, service substitution, patient empowerment, clinic accreditation, transportation (and rural versus urban divide), staff pay and correlation of facility level incentives in staff turnover, training/ capacity building…

I want to address the most salient issues in separate posts. In this post, I’ll focus on the discussion about utilization. The chat considered two key points: 1) whether vouchers can increase utilization of services and 2) whether that utilization leads to better health outcomes.

In Uganda OBA project, utilization at contracted clinics increased over the year prior to program launch. It is likely some patients sought care who would have not sought care without the voucher. Also likely some patients opted to visit OBA clinics over other facilities. This “substitution effect” is less desireable than giving “new” patients access to care. In the general population, STI utilization increased between baseline survey (2006) and the follow-up survey (2007). The increase was evident in the control areas and the intervention areas, which raises a few concerns about quality of survey implementation. However, the significantly lower syphilis prevalence in 2007 is consistent with the improved use of STI treatment services. In Uganda, we have evidence that vouchers increase utilization and are associated with better health otucomes.

Generally, we measure utilization at two levels: facilities and the general population. The evidence for observed utilization increases is discussed below with links to reports on both evaluations of both patient and general population evaluations.

Clinic evidence

In the Uganda OBA program, seven contracted facilities had lab books available from the year prior to OBA. Among the seven clinics surveyed, non-OBA client visits for STI-related laboratory tests increased by an average of 32% in the first year of OBA compared to the year prior.  Some clinics saw considerable increases while others recorded a decrease in non-OBA client numbers but on average there was a 32% increase. Total client visits (OBA and non-OBA) increased by 226% for the same period, with all clinics experiencing an increase in the first year of OBA contracts. (See previous post on THDBlog and download the original report [pdf])

We also compared utilization at contracted facilities to the use of public sector STI treatment services. In Mbarara, Kiruhura, Ibanda and Isingiro districts there were approximately 65,000 patient visits in 2005 at 143 facilities (ranging from rural health center IIs to centralized located health center IVs and regional referral hospitals). In the first year of OBA, the 18 contracted OBA facilities saw more than 9000 patients – representing the equivalent of roughly 14% of the total patient load in the district’s public sector the year before.

General population evidence

We carried out a general population evaluation with a pair of surveys in 82 villages and urban cells in 2006 and 2007. Highlights from the executive summary of the preliminary final report are listed below (download report [pdf]).

•    Between 2006 and 2007, awareness of the STI voucher increased more than 25 percent.

•    Recognition of STI symptoms among the general population improved 10 percent between 2006 and 2007.  Sixty-nine percent of respondents in 2006 and 79 percent of respondents in 2007 were able to recognize two or more STI symptoms.

•    Although the most common reason for not seeking healthcare when reporting a health complaint was “lack of money” in both years, 10 percent fewer women cited “lack of money” in the 2007 survey. The second most common reason for not seeking healthcare both years was “distance to provider”.

•    Evidence is suggestive but by no means conclusive that syphilis prevalence fell between baseline and follow-up surveys.  Syphilis prevalence, based on TPHA test results alone, fell six percent between baseline and follow-up surveys. 18 percent of respondents had reactive results in 2006 and 12 percent in 2007.  Syphilis prevalence, based on VDRL lab results alone, fell two percent between baseline and follow-up surveys.  Six percent of respondents had reactive results in 2006 and 4 percent in 2007.  Syphilis prevalence remained unchanged when TPHA and VDRL results are combined – only 3 percent of respondents were reactive on both tests in the 2006 and 2007 surveys.

]]> http://oba-uganda.net/chat-about-utilization/feed/ http://oba-uganda.net/join-us-online-chat-oba-and-vouchers-march-19th/ http://oba-uganda.net/join-us-online-chat-oba-and-vouchers-march-19th/#comments Tue, 17 Mar 2009 04:46:35 +0000 Ben http://oba-uganda.net/?p=95 On March 19th I will be participating in an online conversation about output-based aid hosted by Abt Associates on the PSP-One Project. Output-based aid (OBA) financially empowers patients to make choices about where they receive their healthcare and incentivizes providers to deliver high quality services. The management of OBA systems builds institutional capacity to provide [...]]]>

On March 19th I will be participating in an online conversation about output-based aid hosted by Abt Associates on the PSP-One Project. Output-based aid (OBA) financially empowers patients to make choices about where they receive their healthcare and incentivizes providers to deliver high quality services. The management of OBA systems builds institutional capacity to provide cost-effective care to targeted populations. However, OBA is by no means a panacea to what ails health systems in low-income countries. Join in on the discussion to find out more! Once again it is March 19th:

9:30 am Eastern (United States)
1:30 pm (13:30) Greenwich Mean Time
2:30 pm West Africa Time Zone
3:30 pm Central Africa Time Zone
4:30 pm East Africa Time Zone

If you would like to receive details about the chat or would like to suggest questions for discussion, please email the organizers at: n4a@abtassoc.com. You will need to register beforehand on the Network for Africa. Registration takes 30 seconds at the following link: http://www.conferences.icohere.com/vouchers

First HealthyBaby birth

The first delivery on the new HealthyBaby vouchers took place the morning of February 28th (see Melissa’s post).The delivery took place at Angella’s Domicillary in Rubindi trading center. Mother and baby are both doing well.

The program was launched in September in Mbarara and then issues ranging from reimbursement rates to database development took longer to resolve than initially anticipated, but the program is up and running now. It’s being rolled out in two stages. 11 facilities in the areas within an hour’s drive of Mbarara town are contracted now and 15 voucher community-based distributors do door-to-door selling of vouchers to poor women in rural communities. By May a second phase of 60 providers and many new voucher distributors will be confirmed in districts to the north and west - up to four hours from Mbarara in some cases. In the end, a population of 7-8 million will be covered with an anticipated 110,000 deliveries in the next three years.

In the HealthyBaby program the mother purchases a voucher for 3000 USh (approximately 1.50 USD). A peal-off sticker from the voucher is then submitted with a claim form on each visit. Four antenatal visits are covered by the program as well as the delivery, including any surgery needed then, and postnatal care.

After each visit, the facility submits the claim form with the voucher to the management agency, Marie Stopes International Uganda, which then pays the hospital for the cost of the visit - labs, any prescriptions given, the consultation fee, etc. The attending nurse usually completes the paper form and the mother signs or puts her thumbprint on it. Filling out the forms can be tedious and error prone. The same seems to be true too of much of the government clinic data reported to district health offices and up to the Ministry of Health in Kampala. Record keeping can be improved. Melissa is working to develop digital systems that can help improve communications between the clinics and the management agency, and also decrease the cost and burden of claims administration. More on that later.

The Kenya and Uganda OBA programs were both financed by the German KfW Development Bank and launched in mid-2006.  Recently a film was made about the Kenyan “voucher babies” highlighting one expectant mother in the Kenya program.

Nov 12 update:  I wanted to post this newsletter (KenPop vol 2 issue 3, 1.9MB PDF) with more detail on the Kenya OBA program which sells vouchers for safe delivery, long term family planning products and services, and a rape response service.  Between June 2006 and January 2008, over 73,000 vouchers were distributed in the 5 project sites.  Safe motherhood vouchers made up more than two-thirds of the vouchers sold.

The Uganda program continues to grow and learn.  Berkeley graduate students Melissa Ho and Matthew Hamilton presented at the recent annual meeting of the American Public Health Association (APHA) in San Diego.  Melissa is developing an early version of a mobile medical claims management system for the Uganda OBA program.  Information management is critical for proper patient treatment and valid reimbursement and her system is a big step in the right direction. Her APHA slides are available here.  Matt presented on preliminary findings from the “before-after” population evaluation (hamilton-apha-slides).  We looked at two specific outcomes: knowledge of STI symptoms and syphilis prevalence.  The analysis is crude (my insistence on sharing what we know now) and further work is underway to make the comparison truly comparable between baseline and follow-up surveys.  Knowledge of 7 of 9 STI symptoms appeared to improve between baseline and follow-up.  More promising, syphilis prevalence (TPHA and VDRL results) showed a decline between 2006 and 2007.  A mile-high caveat on these findings - we have yet to control for secular trends and compositional effects in these data.  More coming soon …

The next phase of output-based aid in Uganda has begun to provide subsidized delivery care for 90,000 poor women in the west of the country.  On behalf of the Ministry of Health, Marie Stopes has contracted thirteen facilities with another 70 potential facilities to join in the next nine months.  The voucher is sold by community-based distributors trained to screen potential patients using a MSI-developed participatory poverty grading tool.  Women who qualify pay 3000 Uganda shillings (roughly US$1.40) for a voucher that entitles them to four antenatal clinic visits, delivery care at contracted facilities, and post-delivery care at their choice of facility.

The program was launched September 18th in Mbarara.  Photos linked here.  The Honorable Richard Nduhuura gave the keynote address, copied below.

KEYNOTE SPEECH BY HON. RICHARD NDUHUURA

A friend recently sent a link to this Berkeley database of GIS shapefiles for roughly 245 countries, islands, and principal administrative areas. Themes include roads, railways, inland water, elevation, population, and administrative areas.  If you’ve ever hunted for hard to find shapefiles, bookmark the site. We have been creating a number of maps like the one below of contracted providers in the Mbarara region and I’m curious to see how useful this new database will be.

Update: The same friend (thanks tqlo!) sent this link to the GPS Visualizer’s GeoCoder.  It’s a free service currently run through Yahoo that plots submitted street addresses as coordinates.

The successful initial public offering of shares in the 25% government owned Safaricom is an eye-catching story. Asking whether similar good news in economic and political developments across the continent are a flash in the pan or signs of larger trend, the Boston Review features Berkeley’s Ted Miguel (”Is it Africa’s Turn?“) and nine commentaries.