New project to evaluate voucher programs in five countries

The Population Council has received funding from the Bill and Melinda Gates Foundation to document, evaluate, and share findings on reproduc-tive health voucher programs in East Africa and South Asia. There has been growing interest in “voucher and accreditation” (V&A) strategies for financing health services.

Under this project, the Population Council is preparing to carry out evaluations in Kenya, Uganda and elsewhere. The project will evaluate the impact of V&A programs in facilities and the populations served, mea-suring changes in reproductive health behaviors, service utilization, and health status especially among the poor. The project will also document program and health facility responses to the V&A approach and the effect on business models and programmatic efficiency. The capacity of imple-menting agencies to conduct routine monitoring and evaluation will also be assessed and strengthened.

In Uganda, the voucher program was launched in July 2006 and focused on STI treatment. It was expanded in early 2009 to offer maternal health services to low-income women. The project, funded by the German Development Bank (KfW), is implemented by a team of partners led by Marie Stopes International–Uganda, which manages the voucher distribu-tion, claims and processing, fraud control, quality assurance and provider accreditation. In this project, only private clinics are contracted. The Kenya output-based aid (OBA) program is run by the National Coordi-nating Agency for Population and Development (NCAPD) in three rural districts and two Nairobi informal settlements. This project is funded by the KfW and the Government of Kenya and offers subsidized vouchers for maternal health, long-acting pre- and post-rape care. PriceWater-PriceWater-houseCoopers coordinates the claims processing center and voucher distribution.

Although V&A pilot programs have been implemented in several coun-tries over the past 15 years, little is known about how the various models function in different settings and whether productivity in reproductive health service delivery is improved. Not much is known about how V&A programs affect the operational efficiency of participating service-delivery organizations and individual providers. There is also limited understand-ing of their effect on the quality of care received by clients, on levels of service utilization, especially among the poor and underserved and their impact on reproductive health behaviors and status at the facility and population levels.

The evaluations by the Council will therefore generate much-needed evidence to help governments and partners decide whether to scale up these programs, include additional services, or support their transition to a different finance model.

RH Vouchers newsDecember 2009

Welcome to the first issue of RH Vouchers Project newsletter. The newsletter will be published every quarter and will carry news from the project and about healthcare financing in general.

In between issues, be sure to check out the project blog RHVouchers.org where you will find healthcare finance articles, voucher case studies, project area maps, and voucher service statistics.

We hope you will find it informative.

RH Vouchers Team

How do voucher-and-accreditation programs work?Voucher-and-accreditation (V&A) programs were developed as alternative healthcare financing models to enable economically disadvantaged populations to access essential reproductive health services at a specified level of quality and at an affordable cost. At the core of the programs is a performance-based contract with facilities and vouchers distributed to patients that entitles the bearer to choose care from any contracted health center. Healthcare providers must meet high quality standards to join and then compete to diagnose and treat patients in exchange for the voucher. The vouchers’ cost to the patient is heavily subsidized; in some programs it is free.

The provider is reimbursed at a negotiated rate that reflects the cost of service provision and a reasonable profit. Service providers are reimbursed only after verification of contractually delivered services. Voucher programs are designed with several objectives in mind: to give patients the economic power to demand high quality healthcare, to target high risk or low income patients for critical services, to augment general population utilization rates, and to standardize per-unit healthcare costs and quality. 1Continued on page 2

In the coming months, the project will launch a Vouchers Resource Centre at the Council’s Nairobi office, to serve as the central hub for information distribution and data archiving. Web-based healthcare delivery maps will also be developed, as well setting up an online com-munity and e-conferences for exchanging infor-mation on reproductive health vouchers with partners and other stakeholders around the world.

A population and facility survey will be conduct-ed in Kenya, and at least two business schools will be identified as partners in the project. More information on these activites will be car-ried in the next issue of the newsletter.

Project Management

A strong team of staff will implement the RH Vouchers Project in the five countries. The team will be lead by three key staff from the Population Council: Dr Ian Askew, Mrs Charlotte Warren and Dr Ben Bellows.

Ian D. Askew, PhD, is the Council’s Director of Reproductive Health Services and Research. He joined the Council in 1990, and has more than two decades of experience in reproductive health operations research in some of the world’s poorest settings. Over the past 19 years, he has lived and worked throughout Africa. He has also conducted studies and provided training in Asia and Latin America. Ian was director of the 10-year USAID-funded Frontiers in Reproductive Health program (FRONTIERS). His professional interests include integrating reproductive health and HIV and AIDS services; developing and improving the quality of community-based reproductive health services; understanding the causes and consequences of sexual and gender-based violence; and seeking to eliminate female genital mutilation/cutting. Ian is the project director for the RH Vouchers Project.

Charlotte Warren is an associate with the Popula-tion Council’s Reproduc-tive Health program. She has implemented a range of reproductive health op-erations research projects in several countries of East and Southern Africa. Currently she manages

the Council’s research projects on measuring the impact of integrated HIV and sexual and reproductive health (SRH) services in Kenya and Swaziland. Warren was involved in the ini-tial planning stages of the RH Output-based Aid (OBA) project in Kenya and developed its accreditation criteria. She has extensive experi-ence in managing collaborative programs with ministries of health, academic institutions, and international NGOs, and in-depth experience in project cycle management including design and appraisal, implementation, and monitoring and evaluation. She is the technical advisor and principal invstigator for RH Vouchers project in Kenya.

Ben Bellows is an associate with the Population Coun-cil’s Reproductive Health program in Nairobi, Kenya, and the Program Manager for the RH Vouchers Project. He has more than 10 years’ experience in rural develop-ment and health projects in South America and Africa. Before joining the Population Council, Ben served as a technical advisor to Venture Strategies for Health and Development, leading the evaluation of the Ger-man Development Bank (KfW)–funded voucher program for treatment of sexually transmitted infections (2006–08) in western Uganda and an ongoing population assessment of a KfW and GPOBA–funded maternal safe delivery voucher program in western Uganda. Ben received his Ph.D. in epidemiology (2009) at the University of California, Berkeley. He is the project man-ager and principal investigator for the project in Uganda.

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TAC meeting reviews project design and experiences

In May this year, the first meeting of the Technical Advisory Committee (TAC) convened by the RH Vouchers Project met in Washington DC. The TAC members come from key institutions involved in or knowledgeable of reproductive healthcare finance and reproductive health service delivery. TAC members were briefed on the study’s objectives and then were updated on the status of current RH voucher projects.

The TAC members raised issues to guide the RH Vouchers Project as it carries out its evaluation activities. These included how the reimbursement schedule is reviewed and how the standards of care, financial and technical information are assessed, as well as the monitoring and evaluation mechanisms in place. In designing the evaluation, the TAC emphasized the importance of costing services and to look for opportunities to make comparisons with other service delivery models. The project will also need to determine what kind of evidence will be most useful for different policymakers so that the research and communications activities can be managed accordingly.

The meeting emphasized the role of the TAC in connecting the RH Vouchers Project with similar programs, in order to expand the range of experiences and knowledge that can be documented and shared.

Family Planning vouchers workshop in Nairobi

In September, the Government of Kenya and the PSP-One project hosted a vouchers workshop in Nairobi with a strong focus on family planning. Teams from voucher programs in Bangladesh, India, Kenya, Tanzania, and Uganda came together to share knowledge and experiences on program design, and to discuss challenges as well as possible solutions to improve their programs. In addition to the voucher program participants, there were observers from the German Development Bank (KfW), the World Bank, the German Society for Technical Cooperation (GTZ), the Population Council, Johns Hopkins University’s JHPIEGO program, and representatives of the Kenya government from the National Coordinating Agency on Population and Development (NCAPD) and Ministry of Health.

More about the workshop is on the RH Vouchers blog here http://www.rhvouchers.org/2009/10/nairobi-voucher-workshop-day-2/; and here: http://www.rhvouchers.org/2009/09/nairobi-workshop-5-countries1/

Vouchers deliver much needed services in Uganda

Marie Stopes International Uganda is spearheading an innovative OBA voucher scheme to help poor Ugandans in the southern and western regions to access quality services for the treatment of sexually transmitted infections (STIs) and high quality mater-nal and neonatal healthcare. With financial support from the German Development Bank (KfW) and the Global Partnership on Output-based Aid (GPOBA), MSI Uganda distrib-utes Healthy Life and Healthy Baby vouchers, which entitle the holder to comprehensive STI treatment and maternal and neonatal services at high quality private health facilities.

Service providers are reimbursed only after verifica-tion of contractually delivered services. A contractual relationship ensures that a financial mechanism is con-stantly in place to induce compliance with quality lab and management standards. Vouchers are distributed through drug shops, pharmacies, community-based sales agents and by MSI staff during behavior change campaigns. MSI Uganda implements a strong behavior change campaign to increase awareness of the project and improve client numbers.

Currently, the program is expanding the distribu-tion of the vouchers through 2011. MSI Uganda plans to also sell more than 50,000 subsidized vouchers for pregnant women to access comprehensive safe delivery services at approved private maternity facili-ties across the region. The scheme will specifically target low-income populations, who are most likely to experience untreated complications in childbirth. The program will also scale up STI treatment offering 35,000 double vouchers in the current funding cycle. More than 9,500 vouchers have been redeemed for both safe deliveries and STI treatment since February 2009.

The next issue will highlight the Kenya OBA pro-gram. In the meantime, you can learn more about the program here: http://www.kfw-entwicklungsbank.de/EN_Home/Countries%2c_Programmes_and_Proj-ects/Sub-Saharan_Africa/Kenya/Project_-_Vouch-ers_for_Health.jsp.

MS Uganda workers make a home visit (photo by MS Uganda)

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More information on mapping here: http://www.rhvouchers.org/2009/11/google-mapping-tools

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Other newsFirst ‘voucher baby’ delivered in Uganda

When Jeninah Komugisha, 35 and pregnant with her fifth child, walked into the Angella Domiciliary Clinic with labour pains, she handed in her Healthy Baby voucher and request-ed assistance. A few hours later, she delivered a beautiful, healthy baby girl. “I feel very grateful to the Healthy Baby scheme…. there are many more mothers who ordinarily would find it difficult to access such facilities when deliver-ing simply because they lack the money,” said Jeninah.

The HB scheme is part of the wider output-Based Aid (OBA) initiative in Uganda, which financially empow-ers patients to make choices about where they receive their healthcare. Under the HB scheme women like Jeninah purchase a voucher for 3,000 Ugandan shillings (approximately US$1.50) from a network of Com-munity Based Workers (CBW). She then submits it to her chosen healthcare provider in return for four antenatal visits, delivery services (including surgery if needed), and one postnatal visit. The scheme targets the very poorest in the community to ensure that they have access to quality services and providers that they would otherwise not have.

“It is wonderful to have welcomed the first OBA baby into the world,” said Christine Namayanja, Programme Direc-tor of MSI Uganda. “Since then, five other babies have been born! The HB scheme is proving to be a great success.”

Aasha Pai, Regional Director, East & Southern Africa, said, “This is great news. MSI Uganda has worked hard to expand this project and this is what it’s all for: to increase access and choice for women who seek a safe delivery. There’s increasing interest in OBA approaches from donors and governments to make aid more transparent, and there’s so much other MSI Partners can learn from MSI Uganda’s experiences.”

KfW publishes paper on vouchers

A working paper is available from KfW on voucher schemes as a financing option in the health sector. The paper summarises the experience of German Financial Cooperation with voucher schemes in the health sector. You can download a copy at the follow-ing link:http://www.kfw-entwicklungsbank.de/DE_Home/Service_und_Dokumentation/Online_Bibliothek/PDF-Dokumente_Sektoren-Berichte/Arbeitspapier_OBA_1007_end_EN.pdf

Mapping ‘voucher’ facilities in Uganda

Using available web platforms, the RH Vouchers project has mapped contracted voucher facilities in Uganda, identifying location names, type of voucher accepted and contact information.

This continuing activity will map participating facilities to estimate distance to care, healthcare coverage, and other outcomes of interest to the evaluation. The project is also keen to visualize aggregate voucher data over time to help with routine monitoring and information distribution.

Tel: +254 20 271 3480/1/2/3Fax: +254 20 271 3479email: info-nairobi@popcouncil.orgwww.rhvouchers.org© 2009 The Population Council, Inc

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Jeninah and her new baby