A s part of the Population Council’s evaluation of the Kenya Reproduc-tive Health Output-Based Aid (RH-OBA) voucher program, the team

is currently conducting health facility assessments and population surveys to measure equity, access and quality of care in Kitui and Makueni districts at control and accredited facilities that offer family planning, recovery ser-vices for gender based violence and maternal healthcare.

The health facility assessment will determine whether clients who use vouchers receive better quality reproductive health services compared to those in the control facilities. Key indicators include change in proportion of facility-based births among the poor, improvements in case-fatality ratio, and the frequency of untreated complications in the facility catchment area populations.

The team is carrying out detailed data collection at control and accredited facilities including observation of client-provider interaction, patient exit interviews, facility inventory, record reviews, and service statistics in the past 12 months. In the population surveys, the team will conduct house-hold interviews among women who have delivered in the past 12 months, among men from the same households, as well as carry out verbal autop-sies in the surveyed areas.

The population survey sampling frame is developed using spatial statistics regarding proximity to accredited and control facilities to control for po-tential confounding by distance to care. Similar data will also be collected in Kiambu, Kisumu, Nairobi, and the Coast for analysis and results shared with stakeholders through dissemination meetings and project briefs be-fore returning to the field to conduct follow-up assessments.

The RH Vouchers Newsletter The Reproductive Health Vouchers news-letter is a quarterly publication of the Population Council providing news about the RH Vouchers project and healthcare financing in general.

The RH Voucher Project The Population Council, through the Re-productive Health Voucher Project, is un-dertaking evaluations of Voucher & Ac-creditation programs to generate evi-dence that can help governments and partners decide whether to scale up these programs, include additional ser-vices, or support their transition to a dif-ferent model. The evaluations are taking place in East Africa and South Asia under a four-year project funded by the Bill & Melinda Gates Foundation and in collaboration with KfW, the German Development Bank.

www.rhvouchers.org

The Population Council The Population Council conducts re-search worldwide to improve programs, policies, and products in three areas: HIV and AIDS; poverty, gender, and youth; and reproductive health.

www.popcouncil.org © 2010 The Population Council, Inc

Population Council | RH Vouchers Newsletter | April 2010

In this issue we update you on the Popu-lation Council’s evaluation of the Kenya OBA project which is currently being redesigned and expanded. Anrudh Jain’s commentary identifies two key facility indicators that incentivized health care programs should track. We highlight several new publications with lessons for healthcare finance and profile one of the Kenya Voucher pro-jects from www.rhvouchers.org

A potential client is asked about her assets as part of the screening process to identify the poor. Poverty markers included housing, medical access, wa-ter source, sanita-tion, rent, income and number of meals per day. Photo © Richard Lord.

Baseline Health Facility Assessment

In Anrudh Jain’s Economic & Political Weekly commentary, “Janani Suraksha Yojana and the maternal mortality ratio”, he questions the standard assumption that more facility births will save mothers’ lives, arguing that incentivized delivery programs may disproportionately draw uncompli-cated pregnancies to facilities and use scarce resources that would otherwise treat complicated cases. Jain suggests monitoring two key facility-level indicators to determine whether the program is reaching the intended mothers: 1) the proportion of pregnant women with complications among institutional deliveries, and 2) the case-fatality ratio among complicated cases at these institutions. To effectively reduce the maternal mortality ratio (MMR), women with pregnancy complications ought to be seen by individuals with sufficient training and supplies to treat those complications. Demand-side incentive programs may increase the frequency of proper care but such an increase cannot be assumed. For instance, if the proportion of com-plicated deliveries at contracted facilities falls after the in-troduction of demand-side subsidies, the program may not have reached the women most in need of the facility’s ser-vices. And if the case-fatality ratio among complicated cases increases at contracted facilities, access may have improved but the facility’s ability to provide high-quality maternity care has likely been over-whelmed.

Do incentives for more institutional deliveries result in lower maternal mortality?

Photos from the field Photographer Richard Lord visited the Kenya Reproductive Health Output-Based Aid (RH-OBA) Voucher Program in January and documented the day-to-day activities of the voucher program in the capital city of Nairobi and rural Kiambu district. The photos below were taken in Pumwani Maternity Hospital in Nairobi, one of the 54 RH-OBA ac-credited health facilities in Kenya. The facility is Nairobi’s oldest and largest obstetric referral hospital. It offers mater-nity and neonatal health services at highly subsidized cost to the poor, which stretches its capacity to handle on average 80 deliveries¹ per day. In Phase I of the program there was a 79% increase in caesarian sections at other OBA facilities in Nairobi, relieving Pumwani of some of its poor patients and bringing in additional revenue from new voucher clients who rely on Pumwani². ¹ Nairobi City Council Official website. ² Mati. JKG, Maua. JM, Kagera. S, Kundu. F, Ochieng. G, Albrecht. M, Janisch. C, Stallworthy.G and Homan. R. “Report of the Mid-term Review of the Reproductive Health–Output-Based-Approach Project in Kisumu, Kiambu, Korogocho and Viwandani.” Na-tional Coordinating Agency on Population and Development (NCAPD), 2008.

2

Above left: A mother and her newborn baby at Pumwani. Center: A father holds his newly born ‘voucher’ baby at the same facility. Right: A client undergoes an implant insertion as part of Pumwani’s Family Planning outreach.

Jain’s concern is borne out in a maternal health study in Matlab, Bangladesh which found that maternal deaths were much more frequent among facility deliveries than home births throughout the study period 1987-2005 (2188 facility deaths per 100,000 pregnancies versus 160 home-based deaths per 100,000 pregnancies for women who did not seek facility care; crude OR=14; 95% CI=10-20)¹. Despite the clear temporal improvements in the MMR, Jain’s commentary raises the concern that a decline in the average MMR does not adequately measure the impact of investments in facility service quality. Over time a disproportionately higher (or lower) number of women at risk of complication may have sought care at a facility where improvements were made. Without measuring the case-fatality ratio among complicated cases, it is not pos-sible to know whether the investments in facility service quality paid a health dividend for clients most in need. Population Council former Vice President and Distinguished Scholar Anrudh K. Jain has had a leadership role in global reproductive health programs at the Council for over 20 years. http://beta.epw.in/newltem/comment/67519/ ¹) Ronsmans, C., Chowdhury, M.E., Koblinsky, M., Ahmed A., “Care seeking at time of childbirth, and maternal and perinatal mortality in Matlab, Bangladesh”. Bull World Health Organization 2010; 88: 289-296 doi:10.2471/BLT.09.069385

Country Program Profile Summary – Kenya

Program title Reproductive Health Output-Based Aid (RH-OBA) Voucher Program

Location Kisumu, Kiambu, and Kitui districts. Korogocho and Viwandani slums (Nairobi)

Period 2005-2012; Constituting Phase I (October 2005-June 2009) and Phase II (July 2009 –2012).

Background This voucher scheme, co-funded by the German Development Bank (KfW) and the Kenyan government (US$ 9.55 million for Phase 1), offers a safe motherhood package of antenatal services and attended delivery by qualified health workers, long-term family planning methods and gender-based violence re-covery services at accredited facilities. The safe motherhood voucher cost to clients is Ksh 200 ($2.70) and the Family Planning voucher is Ksh 100 ($1.35), while the service providers are reimbursed up to a maximum of Ksh 20,000 for complicated deliveries.

Partners Donor: German Development Bank (KfW), Government: Ministry of Public Health and Sanita-tion/Ministry of Medical Services, Project Management Unit: The National Co-ordinating Agency for Population and Development (NCAPD), Monitoring and Evaluation: Population Council, Voucher Man-agement Agency: PriceWaterhouseCoopers (PWC), Technical Advisor: IGES GmBH (Phase I), EPOS Health Management (Phase II).

Numbers served Between June 2006 and Feb 2010: 82,523 Safe Motherhood claims, 12,643 family planning claims and 480 gender violence recovery claims were submitted. 93% were reimbursed.

Service provider reim-bursement rates

Exchange Rate

75 Ksh=US$1

ANC: Ksh 975 ($13) Normal delivery: Ksh 4,950 (US$66) Caesarian delivery: Ksh 20,700( US$276) Surgical contraception (BTL or vasectomy): Ksh 2,925 (US$39) Implants: Ksh 1,950 (US$26) IUCD: Ksh 975 (US$13)

Poverty grading To ensure accurate targeting of the poorest and economically most vulnerable voucher recipients, a participatory poverty grading tool was used in the project districts developed with indicators specific to each district. Markers for poverty included housing, medical access, water source, rent, sanitation, in-come and number of meals taken per day.

Marketing/Health edu-cation

Advertising agency was used to implement a one-month launch campaign to increase awareness about Family Planning and Safe Motherhood vouchers. Channels included radio spots, road shows, community events, door-to-door communication and use of IEC promotional materials.

Evaluation findings Uptake for Safe Motherhood package services was higher at 77% redeemed vouchers compared to Fam-ily Planning services which redeemed 41% of the total distributed vouchers indicating popularity of the voucher program in eliminating economic barriers for poor pregnant women who previously did not deliver at facilities. Anecdotal evidence has for instance shown that women in Kitui purchased the vouchers as insurance against delivery complications rather than with obvious intentions to use for nor-mal deliveries. At facility level, there has been an increase in deliveries even among non-voucher clients.

Evaluation gaps Impact on health status and utilization at population level remains unknown, a factor which will be ad-dressed by the Population Council’s evaluation of the RH-OBA Voucher Program.

Current status Phase I of pilot completed. A design mission is underway for Phase II. Experiences and lessons learnt in Phase I will be incorporated in the redesign and strengthening of Phase II including a shift of overall pro-ject management from NCAPD to the Ministry of Public Health and Sanitation

Innovations Unlike other voucher programs, both private and public sector facilities were contracted in Kenya al-lowing for greater competition and better service coverage. This ensures that the government only re-imburses the public facilities for specific service based on their service costs rather than on an input-basis.

3

Recent Reports & Publications

Yogita Mumssen, Lars Johannes and Geeta Kumar. Output-based Aid: Lessons Learned and Best Practices. World Bank, 2010.

The authors analyze nearly 200 OBA projects in water and sanitation, energy, health, roads, telecommunications, and education. They found that OBA had advantages over supply-side finance approaches in terms of efficiently targeting subsi-dies and mobilizing the pri-vate sector to serve poor households that would otherwise go without im-proved services. They further suggest, like Eichler and Levine, that monitoring for results is possible, if appropriate monitoring and informa-tion systems are put in place.

Rena Eichler and Ruth Levine. “Performance Incentives for Global Health: Potentials and Pitfalls.” Center for Global Development, 2009.

In a recent paper from the Center for Global Development, “Performance Incentives for Global Health”, Rena Eichler and Ruth Levine acknowledge that while the concept of incentives is often easily understood, the design and implementation can be complicated. Similar to vouchers, performance incentives are transfers of money or goods conditional on taking a measurable action or achieving a predetermined performance target. While evidence increasingly shows that performance incentives can increase healthcare quality for the under-served, design and implementa-tion require flexibility. Eichler and Levine note that monitoring requirements should mo-tivate managers to improve their information systems without condoning falsification. There is a need to combine independent evaluations and provider self-assessments with random audits and penalties for discrepancies to ensure information validity. They also suggest that contracts and performance agreements must specify transparent targets, explain measurement methods and detail how payment will be linked to performance. Contracts should also specify mechanisms for resolving disputes and reasons for termination. Their paper points out common pitfalls such as lack of consulta-tion with stakeholders on incentives design, inadequate explana-tion of rules or creation of a program where providers are asked to take on too much financial risk or conversely too little.

SHOPS mHealth eConference, May 5th This USAID-sponsored initiative, Strengthening Health Outcomes through the Private Sector (SHOPS), is holding an e-Conference to highlight innovative mHealth applications. The RH-OBA Voucher Project is presenting the use of an SMS platform to coordinate communication with more than 100 providers and voucher distributors across western Uganda. Registration is required to access the online conference at this link: http://www.conferences.icohere.com/mHealthSHOPS More information about the conference, at the Global Health Ideas Blog. http://www.globalhealthideas.org

37th International Global Health Council Conference (Washington DC), June 14-18th

The GHC attracts more than 2,500 participants each year to DC. This year the RH-OBA Voucher Project has or-ganized a panel with representatives from Pakistan, Uganda, Kenya and Bangladesh voucher programs. The panel is tentatively scheduled for June 17th at 10.30am. www.globalhealth.org/conference_2010/view_top.php3?id=990

Global Maternal Health Conference (New Delhi, India), Aug 30th —Sept 1st The Population Council is helping to organize this technical and programmatic meeting focused on maternal

health. www.maternalhealthtaskforce.org First Global Health Systems Research Symposium (Montreux, Switzerland), Nov 16-19th

This research symposium will share evidence, identify gaps in critical areas and promote global health systems re-search. Several panels on healthcare finance organized by the German Technical Cooperation Agency (GTZ) and the Population Council will include RH Vouchers Project representatives. www.who.int/alliance-hpsr/alliancehpsr_symposiumbrochure_2010.pdf

4

In addition to our newsletter and blog you can learn more about vouchers at these upcoming events.

It also cautions against having too many perform-ance indicators, insisting on unattainable targets or failing to empower managers to respond fully to the new incentives. While performance incentives are a promising mechanism for better health outcomes there is a need for strong and robust information systems so that lessons can be used to evaluate and revise the programs.