Bellows-Vouchers for UHC

7/30/2019 Bellows-Vouchers for UHC

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Can vouchers help movehealth systems toward

universal healthcoverage?

Ben Bellows

GIC Forum on Health and Social Protection

27 August 2013


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Problem: inequality within country

"Countries across Africa [and Asia] arebecoming richer but whole sections of societyare being left behind.... The current

pattern of trickle-down growth isleaving too many people in poverty, toomany children hungry and too many young

people without jobs."

- Africa Progress Panel, May 2012


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Of 12 MNH interventions in a review ofpublic data across 54 countries, family

planning was the third most inequitable

*Barros, A. J. D., Ronsmans, C., et al. (2012). Equity in maternal, newborn, and child health interventions in Countdown to2015: a retrospective review of survey data from 54 countries. Lancet, 379(9822), 1225-33.


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constraints^3 to financing UHC

in a finite universe Trade-offs in three dimensions

1. Utilization: expand population covered?2. Scope: expand health services offered?3. Financial protection: increase size ofsubsidies per service (or improve

regulation of informal charges)?


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Financing trade-offs

Finance movement toward UHC eitherfrom a greater budget allocation or

greater efficiency

Interventions that generate greatestefficiency will likely operate on supply &

demand


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Voucher functions (management)

Decide to government-run, contract-out, or franchiseConduct provider administrative & clinical training (i.e. CMEs)Design & maintain claims processing & fraud controlMonitor costs, utilization, qualityOffer credit to facilities

FacilityAccredited?Clinical quality?Competition?Reimbursement rates?

ClientPoverty status & need?Voucher is free or fee?Which services

offered?

Program design & functions

Objective reach beneficiaries who in the absence

ofsubsidy would nothave sought equivalent care


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What can vouchers do & where

are the gaps in knowledge?

Recent review catalogued 40 programsthat used vouchers for reproductive

health services (excluded TB andcoupons for health products)

Summarized evidence from multiplestudies of 21 voucher programs


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Number of active reproductive health voucherprograms

0

5

10

15

20

25

30

Small ($1m /yr)


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Program contracts with public & privateproviders

18

6

10

1

5

0

2

4

6

8

10

12

14

16

18

20

private mostly private mixed mostly public public


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Outcometype

Number ofstudies

Direction of effect & gaps in research

Equity ortargeting

8 studies Positive effects: inequalities werereduced.

Missing: nationally standard measures.

Costing 4 studies Positive effects: OOP spending reduced.

Missing: cost-effectiveness,administrative-to-service delivery ratio

Knowledge 5 studies Positive effects: increased knowledge of

important health conditions.

Missing: measures of community normsand partner knowledge.

Evaluation outcomes (1 of 2)


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Outcometype

Number ofstudies

Direction of effect & gaps in research

Utilization 17 studies Positive effects: increased use of ANC,facility deliveries and contraceptives.

Missing: Postnatal care.

Quality 8 studies Positive effects: improved customer care,infrastructure upgrades.

Missing: clinical care scores.

Health 8 studies Positive effects: decreases in STIprevalence, fewer stillbirths, fewerunwanted pregnancies

Missing: maternal mortality, DALYsaverted, CYPs

Evaluation outcomes (2 of 2)


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Prospective studies 2009-2013

Quasi-experimental design for voucherprograms about to launch or expand

Measure change in: utilization (new users, aggregate use) equity (concentration indices, standard

quintiles)

quality of care frameworks (Donabedian,Respectful Care, facility investments) out-of-pocket spending on healthcare


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Data sources:

2 rounds of household surveys 4 voucher & 3 non-voucher

sites

5 km radius from voucher &comparison facilities

Births within two years beforesurvey

2010-11: 962 births among2,933 women 15-49 years

2012: 1,494 births among3,094 women 15-49 years

Study #1, Demand: Study of voucherutilization in Kenya


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Analysis

Cross tabulation with Chi-square tests births by place of delivery over time

Multilevel random-intercept logit analysis ()= +

Three arm design 2006 voucher arm: respondents within 5km of

facilities in program since 2006 2010-11 voucher arm: respondents within 5km of

facilities added to program in 2010 & 2011 Comparison arm: respondents within 5 km of non-

voucher facilities

14


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2006 voucherarm

2011 voucherarm

Comparison arm

Place ofdelivery

Firstsurvey

Secondsurvey

Firstsurvey

Secondsurvey

Firstsurvey

Secondsurvey

Home 32% 21% 59% 47% 45% 42%

Healthfacility

66% 79% 39% 51% 54% 57%

Publicfacility

45% 49% 32% 36% 41% 44%

Privatefacility

21% 30% 7% 15% 13% 13%

p-value p


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Outcome 2006voucher arm

2010-11voucher arm

Comparisonarm

Facilitydelivery

2.04**(1.40-2.98)

1.72**(1.22-2.43)

1.32(0.96-1.81)

Home delivery 0.53**(0.36-0.78)

0.61**(0.43-0.85)

0.75(0.54-1.03)

Adjusted odds ratios

Changes consistent with increased use ofvouchers by respondents 2006 voucher arm: 20% -> 43% 2010-11 voucher arm: 11% -> 45% Comparison arm: 0% in both rounds


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Limitations of analysis

Teasing out direct and indirect effects ofthe program on facility delivery

Identification of respondents withinspecified distances to facilities could affect

over or under-estimation of impact

Most covariates for multivariate analysispertain to time of interview Changes in time dependent co-variates

could affect access to facilities


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Study#2,Supply:Facilityuseof

reimbursements

Crosssectionaldatafrom77accreditedfacilities Retrospectivemeasurementofhowaccredited

facilitiesallocatedrevenuesacrosssixstandardcostcategoriesforphase1(2006-2008)andphase2(2008-2011)

Astructuredquestionnairesenttoaccreditedfacilities

88%responserateachieved Responsesanalyzedtoshowpercentagesof

revenueusedinstandardaccountingcategories


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UseofrevenuebycategoryinPhase2

9% 6%

33%35%

11%

7%

0%

5%10%

15%

20%

25%

30%

35%

40%


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Revenuesourcebeforevouchersprogram

PriortotheGoKVoucherprogram

81%ofthefacili7esreportedthatfollowingthelaunchofthe

voucherprogram,thevoucherprogramhasbeentheirmainrevenue.

RevenueSource

PublicFacilities

PrivateFacilities

FBOs

Government 50% 0 0

Self-generatedrevenue

31% 57% 53%

BankLoans 0 43% 0

Donors 19% 0 37%


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Facilitiesalsoreported

Challengesinaccessingandpurchasingmedicalandnon-medicalsupplies.

Voucherrevenueusedto:

1. CoverthefinancingshorDallforpurchases2. Increasecapacityandprovidemoreservices3. Improveservicequalityandincreasepa7entvolumes/

bedcapacity

Flexibilityinusingrevenuemayhelpovercomeperennialproblemsofcentrallymanaged,publicsectorsupplyandcommodityconstraintsandprivatesectorfinancinggapstoprovidebeMerhealthcareservices.


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In a scaled vouchers strategy thatmoves us toward UHC, which trade-offs would be less painful than others?

Is this a more efficient option p thanalternatives?


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US$millions 70%coverageof2lowestquintiles

2013 2014 2015

Servicedeliverycost 23 29 32

Managementcost(15-20%) 3 6 6

Totalcost:Maternalvoucher 27 35 38

%MOH2011-12budget$813m 3.3% 4.3% 4.7%

Familyplanningservicecost 16 17 20

Managementcost(15-20%) 3 3 3

Totalcost:FPvoucher 19 20 22

%MOH2011-12budget$813m 2.3% 2.5% 2.7%

Think like a demographer. An incrementalallocation could take vouchers to scale


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UHC & vouchers - Equity

Voucher clients are often identified as poor,with a low likelihood of using care

Vouchers educate households to use service,even when the service is free (patientscharter)

Vouchers can control informal payments Vouchers provide managers with data on

eligible households, utilization, and feedbackon populations that need extra mobilization

Vouchers can be targeted to the poor to paytheir insurance premiums


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UHC & vouchers- Financial

protection

Voucher clients receive a subsidy andavoid paying out-of-pocket at point-of-

care Voucher programs often contract

private facilities, which expand accessand improve the likelihood that

households will avoid OOP


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UHC & vouchers- Quality of care

Accreditation standards screen outunderperforming facilities

Reimbursements paid conditional onmeeting minimum service delivery

requirements

Quality-adjusted reimbursements arepossible

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Thank you

RHVouchers.org

@benbellows

[email protected]

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