Can Demand Side Financing, e.g. vouchers, assist Governments to reach MDGs and reduce Maternal...
-
Upload
alban-pierce -
Category
Documents
-
view
214 -
download
0
Transcript of Can Demand Side Financing, e.g. vouchers, assist Governments to reach MDGs and reduce Maternal...
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)"
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
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
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
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