Can Demand Side Financing, e.g. vouchers, assist Governments to reach MDGs and reduce Maternal Mortality?

Anna C. Gorter, MD, PhDInstituto CentroAmerica de la Salud

www.icas.net

Video Conference WHO, Port Moresby, PNG, September 8, 2010

Voucher Baby

Outline of presentation

Demand-side versus supply-side financing Examples of demand side financing What are voucher schemes Potential strengths of vouchers Experiences from vouchers providing safe

motherhood services Lessons learnt and conclusion

HEALTH FINANCINGe.g. Tax revenue or donation

SUPPLY SIDE FINANCING DEMAND SIDE FINANCING

PAYMENT ORGANISATION

e.g. Ministry of HealthPAYMENT ORGANISATION

e.g. Voucher Agency

INPUTSe.g. salaries,medicines, equipment,

etc

RIGHT TOSUBSIDY

e.g. Vouchers, fee

subsidies

HEALTH FACILITIES PATIENTS

Free or subsidizedservices

Redemptionof the rightfor subsidy

PATIENTS HEALTH FACILITIES

Payments

Invoice for Subsidies on Goods and /or services

Co-payments

Supply Side Financing

ADVANTAGES Simple to introduce Cheap to administer Best when the health

services are actually used by the patients who need the services

DISADVANTAGES Difficult to target patients

who need the services but currently do not use these

Low incentive to increase the number of patients

Low incentive to provide services according to the needs of the patients

Demand Side Financing (DSF)Two forms

Patient gets subsidy

The subsidy is given directly to the patient

Health facility gets subsidy

The subsidy is given to the health facility based on a contractual arrangement

Examples DSF where the health facility gets the subsidy

Fee-for-service subsidy claims Referral vouchers Others, e.g.

Cost-per-case contracts Capitation payments Target payments

Examples where the patient gets the subsidy

Given before the health service is used

Cash payment to patients Contributions to family

medical savings schemes Vouchers

Competitive Non-competitive

Given after the health service is used

Cash refunds Conditional cash

transfer (incentive based voucher)

What is a voucher

A document which can be exchanged for defined goods or medical services as a

token of payment

OR 

"Tied cash(as opposed to liquid cash)"

Some examples of vouchers

Voucher scheme

Voucher

Voucher

Voucher agency

Target population

Health Facilities

Donor/ Government

$ M&E reports

Step 4

Step 1 Step 2

Step 3

Voucher $

Important to note

Voucher programmes can contract all health facilities capable and willing to provide the services (public, mission, NGO and private health facilities)

They can function hand in hand with supply side financing of the health facilities

They can be used as a temporary measure to quickly increase the use of a priority services, such as safe motherhood

Strengths of vouchers

Targeting of population sub-groups Encouraging use of particular services Can improve quality Can increase efficiency Payment for services which are actually

provided Facilitates monitoring and evaluation

Targeting

Is a strength when beneficiaries can easily be identified, e.g.

Groups who fear stigmatization people with TB, Leprosy, AIDS

Groups who need priority health services, but do not use them, e.g: Adolescents, young people in need of Sexual and

Reproductive Health Poor pregnant women in need of safe motherhood

services

Vouchers encourage use of important health services

When use is limited by barriers to access (cost, lack of knowledge, cultural barriers..)

Remove cost barriers (incl. eg transport and food or other costs)

Vouchers inform about services and guide users to where services can be obtained

Vouchers can increase quality and efficiency

Quality of services is improved because vouchers incentivise the health facility to respond to the needs of the patients: e.g. friendly services, ensuring medicines are

available, equipment is working etc

Efficiency is increased because only services which have actually been provided, are paid for. This can increase the number of patients using the health facility

Some examples of impact of voucher schemes for safe

motherhood

Kenya India Bangladesh

Kenya voucher scheme, started June 2006

Financed by the German Development Bank KfW Poor in 3 rural districts, 2 urban slums Nairobi To increase access to safe motherhood, family

planning and gender based violence services Public, mission, private, and NGO providers Voucher agency is PriceWaterhouseCoopers Vouchers are sold at highly subsidized prices Over 100,000 vouchers used (especially safe

motherhood vouchers)

Increase in percentage of deliveries

in a health facility in Kenya

44%

15%

71%

90%

54%

23%

0%10%20%30%40%50%60%70%80%90%

100%

Institutional deliveries

DHS all

DHS illiterate

Nairobi slums

Kiambu

Kisumu

KituiVoucher areas

Percentage of deliveries in a health facility with and without voucher schemes (India)

Evaluation voucher scheme in Bangladesh, some findings

34%

19% 21%

55%

38% 36%

0%

10%

20%

30%

40%

50%

60%

ANC Delivery in facility PNC

Control

Voucher

Lessons learntWhat makes vouchers successful?

Appropriate design, committed stakeholders Independent Voucher Management Agency, i.e.

a third party which is able to defend the rights of the patients

Efficient management procedures smooth payment of health facilities

Vouchers address priority health services Vouchers address specific barriers to access

health services (costs, lack of information etc)

Some potential drawbacks of vouchers

Design and set-up is complex (devil is in the detail), needs training of staff at the start

May be susceptible to abuse (black market of vouchers, collusion between health facilities and distributors..)

Program development may take time

However once established vouchers are easy to run and to scale-up, and costs go down

Conclusion I

Vouchers do not replace supply side financing, but strengthen the functioning of health facilities because they motivate staff to produce more and better services

Conclusion II

Vouchers are very good at increasing the use of safe motherhood services by women who currently do not use these services

Great potential in helping to reduce maternal morbidity and mortality

CAMBODIAEXAMPLE IF TIME PERMITS

Cambodia voucher schemes

Successful voucher scheme in MoH facilities in Kampong Cham province (Feb 2007): Targeting poor pregnant women Reduced financial barriers to deliver at facility Made health facility more responsive to women

New voucher scheme financed by the German Development Bank (KfW): Three provinces providing safe motherhood and safe

abortion services as well as family planning services

Results from Cambodia