Productive Health From Promise to Practice

8/17/2019 Productive Health From Promise to Practice

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Tania Boler and Lili Harris

Reproductive Health Vouchers: from promise to practice

Innovation and Best Practice


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© Marie Stopes International 2010 Cover photograph creditHST/ER(TB/FC 03/10) Marco Van Haal

Acknowledgements

Many thanks to the following people: Rehana Ahmed, Vicky Anning, Jamshaid Asghar, Ben Bellows,

Luke Boddam-Whetham, Leo Bryant, Nick Corby, Chris Duncan, Geraldine Ellis, Gillian Eva, Kenzo Fry,

Dana Hovig, Christine Namayanja, Manty Tarawalli, Noah Sprafkin and Maaike Van Min.

For citation purposes: Boler T and Harris, L. Reproductive Health Vouchers: from Promise to Practice”.London: Marie Stopes International, 2010.

Acronyms

ANC Antenatal care

aOR Adjusted odds ratio

CPR Contraceptive prevalence rate

CYP Couple years protectionFP Family planning

GDP Gross domestic product

GPS Global positioning system

ID Identification

IUD Intrauterine device

KfW German development bank

LAPM Long acting permanent method

Le Sierra Leonean Leone (currency)

LTFP Long-term family planning

M-Health Mobile health

MSI Marie Stopes International

NGO Non-governmental organisation

OBA Output based aid

PKR Pakistan Rupee

PNC Post-natal care

SMS Short messaging service

STI Sexually transmitted infection

UGX Ugandan Shilling

USAID United States Agency for International Development


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Contents

Acronyms inside front

Executive summary 5

Chapter One: Introduction 7

The potential of voucher programmes 7

From potential to practice 8

MSI’s experience in voucher programmes 9

About this report 9

Chapter Two: Reaching the poor and underserved 12

2.1 Approaches to poverty targeting 13

2.2 Extending reach: marketing and distributing vouchers 15

Chapter Three: Ensuring a high-quality service 18

3.1 The training and accreditation process 18

3.2 Continual quality audits and checks 20

3.3 Referral and follow-up networks 20

Chapter Four: Reducing fraud and improving efciency 22

4.1 Approaches to reducing the likelihood of fraudulent behaviour 22

Tackling counterfeit vouchers (voucher fraud) 23

Validating claims (distribution fraud) 23

Quality and random checks to counteract service provision fraud 24

Claims processing 25

4.2 The cost and sustainability of voucher programmes 26

Conclusions and recommendations 27


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Tables and Figures

Table 1: Summary of the three voucher programmes 11

Table 2: Three focus countries at a glance 13

Figure 1: MSI voucher procedure 9

Figure 2: MSI HealthyBaby voucher sales, July 2009 - June 2010 15

Figure 3: Voucher design for Pakistan & Uganda 23


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SUMMARY

The challenge for the health

sector is how to increase accessto reproductive health services inhard-to-reach areas where manycommunities can’t afford to accessservices through the private orpublic sector. Concurrently, donorsand host governments are ofteninterested in targeting internationalaid subsidies to the poorest andmost marginalised communities.

In response to this problem, manypublic health-care professionalshave become advocates for theuse of vouchers, which can betargeted at poor people and thenexchanged for a health service.However, the use of vouchers

is still fairly new and there is

little documentation from theseprogrammes about their successesand failures.

Marie Stopes International (MSI) isa non-governmental organisation,providing family planning andsexual and reproductive healthservices to more than six millionindividuals a year in 43 countries.MSI believes in trying out newinnovations in order to addressthe challenges of reaching hard-to-reach populations creatively.Over the last ve years, MSI hasbeen at the forefront of the driveto provide subsidised, targetedreproductive health vouchers. Our

programme leaders have learnt

rsthand some of the inherentchallenges in running a voucherprogramme, as well as some of thecommon factors that can increasethe likelihood of success.

This report brings together theviews and experiences from threedifferent countries – Pakistan,Sierra Leone and Uganda – inorder to share more widely someof the important lessons thathave been learnt. In parallel,MSI is committed to undertakingmore robust evaluations of itsprogrammes in order to shedfurther light on the main issuesthat this report attempts to answer:

Executive Summary

Reproductive health is a fundamental human right and is pivotal to the

well-being of women, men and their families. However, more than 200

million women who would like to delay or avoid pregnancy currently do

not have access to modern contraception. A disproportionate number of

these women are living in poverty.1

© Marie Stopes International / Marco Van Haal


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PAGE TITLE

6

SUMMARY

1) How can we successfully usevoucher programmes to targetthe poor?

2) How can we ensure andmaintain a high-quality service?

3) How can we reduce thelikelihood of fraud, increaseefciency and reduce voucheradministration costs?

Key lessons learnedinclude:

1) Reaching the poor

Targeting vouchers to underserved

or poor people can be an ongoingchallenge for programme designers:

distributing vouchers to an area›with a high density of poor peopleis an efficient targeting method

enlisting local community›members to distribute thevouchers is important forincreasing uptake and forovercoming any communityresistance

distribution of vouchers can also›be a demand generating processthat includes knowledge buildingaround subsidised services (i.e.family planning) to encouragelasting behaviour change and tofacilitate choice

2) Ensuring a high quality

service

As a voucher management agency,MSI has ensured that all servicesprovided through the voucherprogramme meet minimum qualitystandards. MSI goes much furtherand uses the accreditation processas a way of improving the generalquality of the participating privatehealthcare providers:

providing training at the›beginning and ongoing, supportwith opportunities for refreshercourses, helps to maintain highstandards

using a range of quality assurance›tools, such as mystery clients,exit interviews and clinical audits,is important for checking qualityand for reducing the likelihood ofservice provision fraud

setting up strong referral and›follow-up networks calls forpublic and private providers todevelop partnerships, which canbe challenging.

3) Reducing the likelihood of

fraudulent behaviour

In all three countries in this›report, the programme managers

have set up systems to try andreduce the likelihood of fraud.Strategies that show promiseinclude:

investing in strong internal›monitoring and evaluation (M&E)systems

training extensively on data›collection to improve the qualityof data

undertaking random checking›and follow-up of voucherrecipients in order to validate theservice

communicating zero tolerance for›fraud to the service providers andbeing prepared to exclude non-compliant service providers fromthe network.

It is clear that running a voucher

programme is complex andchallenging. Each of theprogramme managers in SierraLeone, Pakistan and Ugandahas come up with creative ideasto overcome these challenges.The results of their efforts arebeginning to show: the averagecost per client provided with a STIservice has reduced signicantlyin Uganda from US $53 to US$21 over the rst four years ofthe programme.i Across all threeprogrammes, vouchers haveenabled more than 71,000 hard-to-

reach men and women to accessreproductive health services.ii

By sharing some of the successesand failures of these programmes,we hope to show the potential of

health vouchers in practice and tobring the health sector one stepcloser to turning the potential of thisexciting innovation into a reality.

i Based on the total number of vouchers redeemed across the three voucher programmes as of August 2010.ii Based on the total number of vouchers redeemed across the three voucher programmes as of August 2010.


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VOUCHERS IN CONTEXT

Despite some gains incontraceptive uptake in somecountries, the highest unmetneed remains concentratedamongst poor people.2 Similarlyfor maternal and sexual healthcare, it is the poor who are leastable to access services. It istherefore more vital than ever tond innovative approaches thatspecically enable poor people toaccess sexual and reproductivehealth services.

For poor people in particular,cost is often the major barrier toaccessing services. In response,the health sector has attempted todevelop models of service deliverywhich specically target the poorwith highly subsidised services.Of the various models available,voucher programmes offer thegreatest potential to providetargeted subsidies to poor peopleand improve the overall quality ofservice provision through betterregulation and accreditation.3-5

The potential of

voucher programmes

Over the last ten years, healthcare providers have increasinglyadvocated for the use of voucherprogrammes to target reproductivehealth services to underservedcommunities.3,6 Voucherprogrammes are seen as an excitinginnovation for the following reasons:

1 .Vouchers ensure highlysubsidised services targetpopulations (usually poorpeople).

Chapter One: Introduction

Sexual and reproductive health services are essential to ensuringmaternal and child health and controlling STIs.Sexual and

reproductive health services in developing countries currently fail to

reach all those in need, however. There are over 200 million women

in developing countries who would like to delay or avoid pregnancy

but who lack access to a modern method of contraception.1

© Marie Stopes International / Peter Barker


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VOUCHERS IN CONTEXT

2. Vouchers are redeemed byservice providers after a servicehas been provided. This meansthat the nancing is contingentupon outputs rather than inputsand is therefore more results

focused.

3. Voucher programmes ofteninclude the accreditation ofprivate providers who jointhe network. This can help toregulate the private sector andimprove the quality of service.

4. Vouchers enable men andwomen to choose where toseek healthcare. This in turn,

creates competition betweenproviders which is expected toimprove the quality of care.

Historically, attempts to reachunderserved and poor communitieshave focussed on providingsubsidies to health providers sothat they can serve those who arenot able to nance their own care.There are a number of shortcomingsto this approach. First, there is noguarantee that, once established, the

subsidised services will be utilisedby the target beneciaries. Second,since the subsidy is provided directlyto the service provider, patients havelittle choice as to which providerthey go to for affordable care. Thismay leave target beneciariesdisempowered and leave providerswith little incentive to improve theirservices.3,6

An alternative approach is to

nance the desired outputs - inthis case reproductive healthservices provided to target groups.This approach is called outputbased aid (OBA). OBA helpsensure that there are incentivesto service providers to achievethe desired outputs, since only bydoing so will they receive funds.OBA is sometimes also referredto as results-based nancing orperformance-based nancing.

The healthcare voucher modelis a type of OBA, as the serviceprovider is redeemed in monetaryterms only after the service hasbeen provided.2,7 Typically, a

voucher programme involves theprovision or sale of vouchers totarget beneciaries (for example,poor people) who can thenuse them at selected public orprivate facilities to receive free

or discounted services. Once theselected facilities have provideda service, they can redeem thevoucher they receive for cashfrom an agency managing theprogramme. This ‘VoucherManagement Agency’ can also limitpayments to services that satisfycertain quality criteria. Serviceproviders subsequently receivepayments according to the quantityand quality of the services provided

to voucher holders.3-5

Through the voucher model,demand for reproductive or sexualhealth services is stimulated sincethe subsidy is given directly to theservice user. Service improvementis then achieved organicallythrough competition betweenservice providers seeking to attractvoucher-holding clients.7,8 Qualitycan be further improved throughthe eligibility criteria used to select

facilities for inclusion in the schemeand to vet reimbursement claims.The means to pay for servicesare provided directly to targetbeneciaries, helping ensure thatthe right people use the subsidisedservices.9-10

Output-based aid, in particularvouchers, encourages bothefciency and quality in services,and enables donors to target

resources. In addition, it makespossible a more effective modelmuch more competent modelof project management for thedonor agency, whereby the donorpayment provides an instantand transparent measure of thatinstitution’s achievements.2 Thisis very popular amongst donorsin the current climate of aidtransparency. A recent World Bankreport describes voucher schemesas one of the few instruments thatallow health planners any degreeof certainty that their subsidies arereaching the intended populationgroups.7 In the long term, voucherprogrammes can also be a useful

stepping stone to setting up large-scale health insurance schemes or

output based contracting.2 3

From potential to practice

Reproductive health vouchers offergreat potential to target subsidisedservices to poor and underservedcommunities.

Voucher programmes can also havea signicant impact upon healthoutcomes. An external evaluation ofMSI’s Uganda programme, which

was undertaken by Ben Bellows(Population Council) and fundedby the German development bank,KfW9 examined the impact ofvouchers on levels of knowledge,utilisation, cost and disease burden.It was based on two populationsurveys of the greater Mbarararegion, conducted in July 2006and November 2007. The resultsshow a strong and sustainedimpact of vouchers: knowledge

of STI symptoms increased 18%between the rst and second years(adjusted odds ratio, aOR=1.43;95% CI=1.22-1.68). Uptake ofSTI treatment among those whoreported having had one or moreSTI symptoms in the previous sixmonths increased 15% in the sameperiod; however, the increasewas not statistically signicant(aOR=1.14; 95% CI=0.89-1.47).Most remarkably, the prevalence ofsyphilis decreased 42% betweenthe two surveys (aOR=0.63; 95%CI=0.48-0.79).9

There is however, littleunderstanding of what works,



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VOUCHERS IN CONTEXT

and of best practice in voucherprogrammes. In part this is dueto the new and evolving natureof the schemes. The scantevidence that does exist suggestsa number of recurring challenges

across programmes related toquality, efciency, equity andsustainability.7 In particular, criticsquestion the ability of voucherprogrammes to target the pooreffectively, as well as questioninghow to ensure quality and how toreduce the risk of fraud.2,7

This paper attempts to answersome of these practical questionsby examining the success and

failure stories of three of MSI’svoucher programmes in Uganda,Sierra Leone and Pakistan.

MSI’s experience in voucher

programmes

MSI is a global, not-for-prot andnon-governmental organisation(NGO) that is committed toupholding the fundamental rightof women and couples to freelydecide the number and spacing of

their children. MSI provides sexualand reproductive health servicesto the poorest of the poor in over43 countries worldwide. MSI isconstantly striving to develop newand innovative ways in which tomeet the unmet need amongst theworld’s hardest-to-reach groups byensuring affordable prices togetherwith unfalteringly high levels ofservice delivery.

As part of its commitment to reachingthe poorest of the poor, MSI hasintroduced highly subsidised voucherprogrammes in ve countries andis participating in a programme ina sixth country. In three countries(Uganda, Sierra Leone andPakistan), MSI manages large-scale voucher programmes. In twocountries (Malawi and South Africa),MSI is piloting male circumcisionvoucher programmes. MSI alsoparticipates as a service provider invoucher programmes managed byother organisations (Kenya).

MSI voucher schemes tend tofollow a similar model, although

this can be altered slightlydepending on the countryprogramme (see Figure 1 for thegeneral operational procedure ofMSI voucher schemes).

A voucher management agency(MSI country programme) typicallyreceives funding to implement theprogramme. The same agency thenprovides vouchers to distributors.The target population is thenapproached through communitysensitisation visits or other marketingevents, which vary amongst theprogrammes. Once clients have agood understanding of the serviceoffered, they receive the voucher

from the distributor and redeem thevoucher at health centres of theirchoice for the service specied.Once the provider has completedthe required service, they submit aclaim to the management agencyfor reimbursement. The type ofreimbursement depends on theprogramme. For example, someservice providers may be entitled toclaim for equipment, whilst otherswill claim for the service/treatmentprovided. Once the claims have

been processed, the vouchermanagement agency will then reportback to the donor with clear anddetailed results about the scheme.

About this report

MSI is committed to identifying,documenting and sharing bestpractice. As part of this commitment,MSI has set up an Innovations and

Best Practice Team to documentand share key lessons learned.Between April and July 2010, theteam worked with the voucherprogrammes in Sierra Leone,Pakistan and Uganda to developa better understanding of whatworks and best practice. The teamanalysed more than 20 internalMSI project documents. Many ofthese documents included researchundertaken by research agencies

and mid-term evaluation reports. Inaddition, telephone interviews wereconducted with key project staff.

This report synthesises the ndingsof this process, highlighting thekey lessons learned from MSI’sexperiences in the three focuscountries. The chapters areorganised as follows:

Chapter Two: How can voucher›programmes best reach the poor

and underserved?

Chapter Three: How can voucher›programmes ensure a high-quality service?

VOUCHER MANAGEMENT

AGENCY

VOUCHER DISTRIBUTERS ACCREDITED HEALTHCARE

PROVIDERS

CLIENTS

DONOR FUNDS

OR GOVT

REPORTS

REIMBURSEMENT

SERVICE

POTENTIAL FEE

VOUCHER

VOUCHER

VOUCHER

VOUCHER

MONEY

Figure 1: MSI voucher procedure


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Table 1: Summary of the three voucher programmes

Pakistan Uganda Sierra Leone

Name of programme Suraj Network Reproductive health vouchersproject

Healthy Life

Healthy Baby

Healthy Life (family planning)

Healthy Baby (Safe Motherhood)

Year started November 2008 August 2008 (safe motherhood &STIs) May 2006 (STIs)

May 2009

Geographical reach Sindh Province and PunjabProvince

20 districts in Western andSouthern Uganda

Healthy Life – 15 slums in theWestern Area :

Healthy Baby – as above plusNorthern and Southern regions

Cost of voucher Free 3000 UGX/ US$1.50 – HealthyBaby & 1500 UGX / US$0.75–Healthy Life

Le1,500 /US$0.375 – Healthy LifeLe3,000/US$0.75 – Healthy Baby

Services included in

the voucher

Free voucher with three servicecoupons: insertion of intrauterinedevice (IUD), removals andfollow-up service and counselling

Treatment of STIs (Healthy Life):Cost of lab tests, treatment, aseparate consultation fee, andthree follow-up visits.

Safe Motherhood (Healthy Baby):4 antenatal care (ANC) visits,facility-based delivery and onepost-natal care (PNC) visit, plustreatment of pregnancy relatedillnesses and management ofcomplications

One LAPM method of choice

Safe delivery: 4 antenatal visits,delivery, 2 ultra sounds and 1post-natal visit that includeslong-term family planning (LTFP)

Reimbursement to

service providers

On monthly basis, privateproviders (PPs) receive paymentsagainst redeemed vouchers;vouchers are reimbursed within15 days of submission to MarieStopes Pakistan

Each voucher costs 200 PakistanRupees (PKR) (US$2.32), which

is paid by MSS on behalf ofclients against each voucher(PKR 150 is for IUD insertion,PKR 20 for follow-up visit andPKR 30 for removal)

STI reimbursement rates rangefrom 9000 UGX (US$4.5) to38,000 UGX (US $ 19) for STDtreatment. The rates includeconsultation fee, laboratoryinvestigations and drugs fromthe agreed national treatmentprotocols for STD management.

For Healthy Baby services, 4 Antenatal and 1 post natal carecost 130,000 UGX ($ 58) fornormal delivery and 314,000UGX (US$140 ) for CaesareanSection -. Emergency transportand other complications arereimbursed on cost

Healthy Life voucher – LTFPservices Le 40,500 (US$10) andTubal Ligation Le 81,000 (US$20)

Healthy Baby: Antenatal –Le 20,250 (US$5) each visit,delivery: vaginal – Le 405,000(US$100), Caesarean Section – Le 1,620,000 (US$400),

Ultrasound – US$10 each visitand post-natal (including LTFP) –US$15

Role of MSI Management agency and socialfranchiser:

MSI provides training, qualityassurance and vouchers

Management agency:

MSI provides accreditation,training, voucher distributionand marketing, behaviourchange communication, qualityassurance, claims managementand provider reimbursement,monitoring and evaluation, fraud

control

Management agency and socialfranchiser:

MSI provides accreditation,training, vouchers, qualityassurance, claims management,monitoring and evaluation

Selection of service

providers

All Suraj franchisees(private providers)

• female private providers

• willingness to provide FPservices

• prior training and experience

• willingness to provide FPservices

• reputation in community

• existing client volume

• formal medical qualication.

Private providers: two tier

First tier for normal births andPNC and STI. Second tier arereferral sites for complicatedbirths

98 for STI & basic obstetriccare (some sites only offerSTI services, whilst others arematernal health-care only)

19 for comprehensive emergencyobstetric care (Healthy Baby)

Process: mapping, contact,quality checking, training,

accreditation

Healthy Life:

Randomly selected BlueStarfranchisees (randomly selectedbecause of ongoing operationsresearch)

Healthy Baby:

Through a process thatincludes mapping, selection,induction, contract negotiations,accreditation


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Table 2: Three focus countries at a glance

Uganda Pakistan Sierra Leone

Population size 31.6 million10 166.1 million11 5.5 million12

% of population living below the poverty line 51.5%13 22.6%13 53.4%13

Contraceptive prevalence rate (CPR) 24%14 30%14 5%14

% of deliveries that are facility -based 41%15 34%16 25%17

Chapter Two:

Reaching the poor and underserved

All three MSI voucher programmes that were analysed for this report

have experimented with different approaches to targeting and reaching

poor and underserved individuals. This chapter looks at some of the

different approaches the programmes used for assessing poverty

levels. It also reviews the evidence about how successful these

approaches have been and some of the innovative approaches for

increasing access to the vouchers.



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2.1 Approaches to povertytargeting

In all three programmes, the targetrecipients for the highly subsidisedvouchers are poor women and men

(in the case of the STI programme). As the vouchers are highlysubsidised, there is an incentive forindividuals of all socio-economicbackgrounds to try to obtain and usethem. It was therefore imperativethat the programme developed astrong evidence-based approachto target poor individuals orcommunities and that checks andbalances were put in place to ensurethat vouchers are really being used

by the poorest of the poor.

Of the three voucher programmes,the KFW- funded Ugandaprogramme is the most mature.The programme has an STItreatment component, which isnot targeted but is available toanyone who wishes to buy thevoucher at a distributing outlet.The programmes safe motherhoodcomponent is targeted at poorwomen.

During the rst year of operations,the programme used a povertygrading tool that was developedby MSI and used in a similarvoucher programme in Kenya.The poverty grading tool ishighly participatory and the localcommunities themselves denepoverty. In order to use the tool,the voucher distributor needsto physically go to the woman’s

house and examine assets andservices in their homestead. Although this tool has beenadopted more broadly outsideMSI, it is highly intensive in termsof both time and resources. Ahome visit is needed to distributeevery single voucher. This ishighly inefcient and very difcultto scale up.

As Christine Namayanja, voucher

project director, points out:

“In some areas, homes are

sparsely located meaning that

community-based distributors

wasted a lot of time moving

between homes. The introductionof geographical targeting removed

the need for a poverty grading tool

and saved a huge amount of time,

– allowing voucher distributors

to reach more women in a day.

Average enrolment of mothers

increased from an average of 12

per day to 25. It also meant that

distributors could easily mobilise

mothers and carry out group

education and voucher selling, thus

leading to greater efciencies.”

Ultimately, targeting specicindividuals within a community willhave high costs. On the one hand,a simple system without homevisit verication is open to leakage(use of the subsidy by unintendedbeneciaries) and yet a morecomplex system – like the one inUganda – is very demanding onresources.

Given these challenges, theUganda programme introducedadditional area-based povertytargeting measures in the poorestsub-counties where povertyincidence is above 50% andpoverty density is above 100people per square km. Underthis denition 25% of all availablesub-counties were ‘poor’ andhome visits were not required. Inthose sub-counties that are not

considered to be the poorest,distributors continue to use theindividual-based poverty gradingtool and home visit verication.iii

The Ugandan programmeundertook extensive secondaryanalysis of national and localpoverty data to ensure that thechoice of ‘poor’ communities wasevidence-based and that the vastmajority of inhabitants in each

community were eligible for thevoucher. In the 2002 Ugandacensus, a national poverty linewas used to differentiate betweenpoor and non-poor households.For example, a wage of 23,150

Ugandan shillings (US $10)iv permonth or less in a central urbanarea is regarded as below thenational poverty line.

Using geographical targeting toidentify those who qualify for thevouchers will help more womenqualify for the voucher, leading to afurther increase in safe deliveries. As it is less complex to administerthan individual poverty grading,

area-based targeting can befacilitated through existing datacollection processes. Using sub-counties rather than larger districtsmeans the population is likely tobe more homogenous. In orderto minimise leakage of vouchersto clients outside the targetedareas, community-based marketingagents ensure that all women areregistered by name and addressbefore they access vouchers.

Even though communities arenever entirely homogenous interms of socio-economic status,given the high levels of povertyacross the country, the problemof a small number of somewhatricher individuals accessing thevouchers within an area canbe far outweighed by the costsavings in using the area-basedapproach. To be more certain ofthese assumptions, the Uganda

programme will undertake exitinterviews or home visits to checkthat the percentage of poorvoucher recipients does actuallymatch their expectations.

Although the Uganda programmehas not yet undertaken this type ofevaluation, both the Pakistan andSierra Leone programmes havea rigorous evaluation componentrunning in parallel to programme

iii Individual-based poverty targeting includes assessing each client individually, usually using a poverty grading tool with indicators such as income and type ofdwelling. It can also include individual home visits to further assess the client’s eligibility. Area-based targeting utilises geographical mapping techniques todesignate whole areas as qualifying for the voucher scheme. Some programmes use individual poverty grading questions in addition to this. Nab. the shift fromindividual to area targeting has only taken place in certain select sub-counties.

iv Based on current market value, September 2010.v In Sierra Leone, MSI is collaborating with the World Health Organization (WHO) on a large quasi-experimental evaluation of the voucher programme. Baseline

data collection was completed in May 2010 and the endline will be undertaken in early 2011. In Pakistan, evaluations have been contracted out and includeprovider surveys, focus group discussions and exit interviews with clients.


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implementation.v

In Sierra Leone, exit interviews areused at both the beginning andthe end of the process (baselineand endline) to assess whether

the proportion of poor clients atparticipating social franchiseesincreases as a result of thevoucher programme. These arealso compared with control sites.18

As in Uganda, the Sierra Leoneprogramme uses governmentmapping statistics to identify thepoorest geographic ‘slum’ areasin and around Freetown in orderto distribute the family planning

vouchers. There are seven areasin the present voucher schemechosen within the Western areaof Freetown. These represent thepoorest dwellings according tostatistical mapping. The marketingagent then conducts ‘asset’based questions with the client toascertain the woman’s access tosanitation and water, as well asfactors such as the type of oorof the client’s dwelling. Althoughself-reported, this additional

questionnaire acts as a furthercheck that the woman really iseligible for the voucher. This dualapproach is quicker to administerthan a home visit.

Although the data are not yetavailable on the poverty levels ofvoucher recipients, the baselinedata shows that 32.8% of familyplanning clients interviewed earnedeither the equivalent of or less than

Le 120,000 (US$30) per month.vi

This means they are categorisedas poor. Importantly, 43% hadnever previously used a modernmethod of family planning.vii Sobefore the vouchers have evenbeen distributed, a high proportionof clients at the facilities are poorand underserved.18

The programme director realisedhowever that this type of area-based targeting, although effectivein Freetown, is more difcult inrural areas where communities aremore heterogeneous:

“In rural communities, land is not

sold; there are no slums. You ndcommunities of diverse socio-

economic status, which impedes

area-based targeting.” Manty Tarawalli, Private Sector

Partnerships Director, Marie Stopes

Sierra Leone (MSSL)

Since the safe motherhoodvouchers are also distributed

in rural areas and are of moremonetary value than a familyplanning voucher, it was decidedto undertake individual povertygrading through home visits for thesafe motherhood voucher only.

Looking across all three typesof programmes, the generalapproach taken is that the lowerthe monetary value of the voucher(e.g. STIs in Uganda), the lesseffort needs to go into assessing

and checking poverty eligibility oftarget recipients. It still remainsto be seen whether or not thisapproach is effective.

In Pakistan, marketing agentsemploy an individual povertyranking tool with nine indicators,viii

which include a mixture ofassets, socio-economic proleand services. The marketingagent conducts door-to-door

visits to identify which womenqualify for vouchers as per thepoverty ranking tool. Marie StopesPakistan consulted differentpoverty ranking tools alreadyavailable for the Pakistan contextand modied them as per the needand targeted population. MarieStopes Pakistan is currently in theprocess of completing an 18 month

study on the Suraj scheme in orderto develop further evidence as tothe effectiveness of the project.

If women score below a certainlevel, they are given a free

voucher. Those women who arenot eligible are referred to thenearest social franchisee, wherethey are expected to pay normaluser fees. In order to ensurethat this approach is working, anexternal agency is tasked withundertaking exit interviews. Thenational average ratio of femaleprimary school attendancein Pakistan is 67%.19 Resultsfrom a round of data collection

in 2010 shows that 48% offranchisee clients had no formalschooling at all, and only 21%had completed primary school(n=98).20 This suggests that theproviders are reaching some ofthe most disadvantaged and poorpopulations (as education level is astrong indicator of poverty level).

The exit interview tool alsoincludes a question on householdincome. Although self-reported,

the results 20 shows that 25% ofwomen at the voucher distributingproviders stated their averagehousehold income at below 102PKR (US$1.20) per day.ix, A further41% earned less than 205 PKR(US$2.40) a day, which is stillbelow the national average.xi

Project staff are also aware thatthe vouchers provide an importantmeans of reaching those who

would not normally accessservices:

“It will be hard without the voucher

system because only (those who

can afford to) will be able to avail

the services.” Female marketing agent,

Punjab Province, Pakistan

vi

Based on current market value, September 2010.vii The percentage of rst-time family planning adopters is a good proxy for reaching underserved communities, as these individuals had never accessed modernFP before.

viii Client’s access to the number of meals per day, housing, fuel for cooking, daily income per family, earning members of family, dependent members of family,water source, sanitation and access to reproductive health services.

ix Based on current market value, September 2010.x Based on current market value, September 2010.xi This is comparatively less than the average Gross Domestic Product (GDP) per capita of 86,415 PKR, which equates to 7,204 PKR or US$84 dollars per month.


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“Removing the cost barrier has

allowed poor women and men

a chance to access expensive

services they would never have

thought of accessing. Private

providers who normally see clients

with money can now serve them.” Christine Namayanja,

Voucher Project Director, Uganda

“Vouchers are the ideal marketing

tool to reach the poor, in present

day Sierra Leone.” Manty Tarawalli, Private Sector

Partnerships Director, Sierra Leone

The preliminary ndings suggestthat vouchers are effectively

targeting poor individuals. Themore rigorous evaluation in SierraLeone will be able to see the extentto which client prole changes withthe introduction of the vouchers.

DIRECT AND INDIRECT COSTS

OF SERVICES

What should vouchers include ifthe poorest of the poor are not tobe excluded? At the moment, thevoucher covers the direct cost ofthe health service. However, the

Uganda programme has foundthat some women are so poor thatthey cannot afford the transportneeded to bring them to the serviceprovider. Although the vouchers donot currently include transport costs,these indirect costs are substantialand should possibly be consideredas part of demand-side nancing.

2.2 Extending reach:marketing and distributingvouchers

Poverty targeting is importantto ensure that the vouchers are

distributed to the correct targetpopulations. In addition, themechanism by which the voucheris marketed and distributed is keyto ensuring effective targeting ofunderserved areas and to ensurethat uptake is high. In Pakistan, themarketing agents made vouchersavailable to clients in their homes,whereas the vouchers in Ugandawere initially available in retailoutlets like pharmacies but were

then brought closer to clientsthrough a variety of communitygroups. Voucher distributiondepends on the type of voucherand the level of subsidy included.For example, in Pakistan thevouchers are free and offer a freefamily planning service. Similarly inSierra Leone, the family planningservice is very highly subsidised.In both these two programmes thedemand is very high as a resultand it is fairly easy to distribute the

voucher.

In Uganda, the safe deliveryvoucher is not so easy to distribute,as the target population is smaller:poor and pregnant women.During the rst year of roll out, thedifculty in nding eligible womento buy the voucher led to low

uptake. The Uganda programmeresponded by undertaking amulti-faceted awareness raisingcampaign. The team used radiotalk shows to discuss reproductivehealth issues and to advertise the

voucher scheme. The reach ishuge: in one three-month period, itis estimated that 12 radio sessionsreached more than 3 millionpeople in West and SouthernUganda.21 Combined with intensivecommunity sensitisation activitiesand incentivising sales teams,the average number of vouchersdistributed per marketing agentincreased from 55 to 198 duringa three-month period – a 360%

increase.22

Figure 2 denotes ‘HealthyBaby’voucher sales in Uganda from2009-2010. The vouchers areused to provide three visits toa centre for antenatal care,delivery and postnatal care. Thegraph demonstrates a sharp andcontinual rise in voucher salesevery month, reecting the successof the programme so far.

For the STI vouchers, theUganda programme decided toincrease the range of partnersselling the voucher. In 2006,when the STI programme rststarted, the vouchers were onlydistributed through drug shopsand pharmacies. The marketingagents employed a face-to-face

Uganda HealthyBaby voucher sales, July 2009 to June 2010

Month

V o u c h e r N u m b e r s

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN

1738

1207

1491

2303

2796

3818

4071

4778

5196

6651

7597

8873


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ENSURING ACCESS

approach to ensure that tradersstocked the vouchers, but also toget feedback on market attitudes

and perceptions of the scheme.21 In general, this approach was notdeemed to be effective in reachingthe large number of people neededto make a real difference to theincidence of STIs in the region.The programme therefore decidedto be creative in the type of groupsinvolved in raising awarenessabout the voucher and approachedorganisations working with thehighly vulnerable or poor. The

groups included youth groups,churches or sex workers.

“The use of local based

organisations and opinion leaders

or champions from churches, youth

and women’s groups, political

leaders and village health teams

has not only been instrumental

in promoting the project and

vouchers services, but greatly

reduced stigma, built condence inhealth service provision and most

importantly promoted community

empowerment and uptake of STI

treatment services.” Christine Namayanja,


Given the stigma surrounding STIs,the Uganda programme has alsobeen careful about how it recruits

the marketing agents:

“We look for someone who knows

the community well and is trusted.

Our marketing agents need to

talk about private and condentialissues and yet they are also selling

something so it is a ne balance.” Luke Boddam-Whetham,

Senior Programme Support Manager,

Marie Stopes International

In Pakistan, the programmehas also worked closely withcommunities in order to break

down myths and misconceptions.In Pakistan, the challengeis to market and distributethe vouchers in highly ruralcommunities that have not hadmuch exposure to family planningor communication on sexual andreproductive health matters.

CHANGING COMMUNITY ATTITUDES TOWARDSREPRODUCTIVE HEALTH

Although generally known as marketing agents or community-based distributors,these community members do a lot more than just distribute vouchers. Eachof them plays an important role in educating communities about the benets offamily planning and safe deliveries. In both Pakistan and Sierra Leone, this isbeginning to change men’s attitudes too:

“Men are happy about the affordability of services and there is a visible

improvement in male involvement as they now understand the benets of safemotherhood and they do all they can do nd money to buy the voucher.” Christine Namayanja,


“From the start of the Suraj initiative we have involved men as key communitystakeholders. When a husband is opposed to his wife using the family planning

services, the marketing agent will arrange a joint meeting with the husband and

the wife in order to try and explain the services fully.” Jamshaid Asghar,

Manager Private Provider Partnership, Pakistan



17/3217

ENSURING ACCESS

“The distribution of the vouchers

has been complicated. The

distances covered by the

community-based distributors is

wide, as rural communities tend to

be sparsely distributed. This really

impedes our ability to distributelarge numbers of vouchers.”Field worker marketing agent, Pakistan

In some instances, this lack ofknowledge has led to communityresistance, particularly fromreligious or community leaders andfrom husbands and mothers-in-law,to a lesser extent.23

As one marketing agent remarked:

“Some people still do not have

positive views about a chala (IUD)

and they share these rumours with

their community without conrmingas some believe that a chala

moves up in (the) body and can

reach to the neck and can lead to

death.” Field worker marketing agent, Sindh

Province, Pakistan 24

Marie Stopes Pakistan decided to

employ local married women to actas the marketing and distributionagents who were viewed astrusted members of the community.The agent meets with the localleaders to gain their approvalbefore starting distribution of thevouchers. As one marketing agentcommented:

“If she (the marketing agent) is

according to the criteria of the

community, they will listen to

her but if she is inappropriately

dressed, then the women of the

community will feel uncomfortable

in talking with her and consider hera bad inuence.” Field worker marketing agent, Punjab

Province, Pakistan24

The agent then visits eachresidence in turn, distributingleaets, identifying potentialclients, giving referral cards,holding follow-up visits before orafter any service, and providingmore information if necessary

to raise awareness and changeattitudes. The agent givescompletely condential andimpartial counselling and ensuresthat the counselling is individualso as to minimise pressure fromthe family. If a woman choosesa family planning service thatis not included in the voucherprogramme, then she is referredto the local Suraj franchiseefor short-term methods andthe Marie Stopes clinic where

prices are highly subsidised forpermanent methods and abortioncare if necessary. Through thispersonalised counselling approach,most marketing agents report thatthey are able to challenge mythsand change perceptions aboutfamily planning.24

This face-to-face marketing issupported by Suraj branded clinicwall murals and up to 150 postersthat are pasted on walls in eachcommunity each month. The localMarie Stopes clinics supplement

the marketing activities throughadvertisements on TV, radio and incommunity groups.

In Sierra Leone, there are far fewerchallenges involved in distributingfamily planning vouchers than inUganda or Pakistan. The mainreason for this is that the vouchersare distributed in very denselypopulated slum areas. There areoften queues of women who all

want the voucher. The challengein Sierra Leone is to ensure thatall women hear about their familyplanning options, not just thosewho receive the voucher. Also,women that do not receive thevoucher need to be informedwhere to go for quality servicesand encouraged to pay out of theirown pocket to avail the services.

KEY LESSONS ON MARKETING

develop targeted activities›and address the myths andmisconceptions related to eachcontraceptive method

use satisfied clients to promote›a voucher scheme

aim marketing at potential clients›and potential service providersso that they understand the valueof the programme.


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MAINTAINING QUALITY

Voucher programmes workby having a large number ofprivate or public providersoffering a standardised healthservice. Before vouchers areintroduced, private providers maybe operating in a less regulatedenvironment or providing servicesof varying quality. As the vouchermanagement agent, MSI hasthe responsibility to ensure thatthe participating providers are alloperating at a minimum standardof quality.

There are three main ways inwhich these three MSI voucherprogrammes ensure and guaranteequality of care:

1) Providing training andaccreditation (which becomesmore important to verify thestandards of the franchisees).

2) Undertaking continual qualityaudits and checking (internaland external).

3) Setting up and ensuring follow-up and referral networks.

3.1 The training andaccreditation process

In all three countries analysed, anyservice provider that wishes to beinvolved in the voucher programmeneeds to be accredited. In order tobe accredited, the provider needsto meet certain minimum qualitystandards and be trained on eachelement of service delivery relatedto the voucher.

Chapter Three:

Ensuring a high-quality service

A complementary and crucial part of every voucher programme is

quality assurance and accreditation. This chapter rst explores how

each voucher programme maintained a standard minimum level of

quality across voucher service providers. It then looks at how voucher

programmes have the potential to regulate and improve the quality of

a private provider network.



19/3219

MAINTAINING QUALITY

In Pakistan and Sierra Leone(for HealthyLife vouchers),the training and accreditationtakes place as part of a socialfranchising model. Providersthat pass the training and meetthe quality standards are thenbranded as part of the MSI socialfranchise network (typically‘BlueStar’). Being part of the

network means that the providermeets the quality standards andmen and women associate thebrand with a high-quality service.

The training improves standardsand also condence. As oneprovider commented:

“It (the training) has benettedus a lot. Compared to before, we

are now more condent. We are

giving very good services to the people. Previously, we were also

unaware and less condent that

CHOICE AND INCENTIVES IN SIERRA LEONE

It is possible to offer a range of family planning services through vouchers and yet still have method-specic vouchers. InSierra Leone, for example, the programme distributes specic vouchers for female sterilisation, implants and IUDs. Variousmeasures are put in place to ensure that there is freedom of choice of family planning methods at all times. For example,voucher distributors are trained extensively on how to counsel each eligible woman on the various options. As part of thiscounselling process, the eligible woman and the voucher distributor identify which method best meets the woman’s needs andshe will be given a voucher for that method. Since vouchers do not include short-term methods, women who would prefera short-term method are given referral cards that will direct them to a recommended family planning provider. These referralcards also allow MSI to track and ensure choice.

The distributors are MSI staff and they are nancially rewarded for their work, but this is not in any way based on the type ofFP method, or number of FP acceptors, as this could restrict choice. Lastly, when a woman attends a clinic to redeem hervoucher, measures are in place to ensure that freedom of choice remains intact. Women who change their mind – whetherbefore or after the consultation – have the option to switch to a different method from the method specied on the voucher.

BLUESTAR SOCIAL FRANCHISING

BlueStar is a social franchise developed by MSI to expand service delivery andcontribute to national health goals through private providers. Social franchisescreate and support a network of existing private providers to offer high quality healthservices and contribute to improving service in the private sector as a whole.

BlueStar strategically selects private providers located in underserved areaswhere income levels are generally low. The aim is to meet the needs of harderto reach groups, who might not otherwise have access to family planningcounselling, commodities and services. Most private providers apportion family

planning as a low percentage of their sales. BlueStar aims to increase salesfrom an average of 3-7% to 10-15%, thus making the concept more appealingto vendors. In addition, BlueStar supports franchisees with branding, training,community demand creation events, as well as clinical and marketing assistance.This support is dependent on the franchisee agreeing to routine supervision,submission of monthly reports, adherence to specied quality standards and anannual franchise fee.

As of 2010, MSI has set up nine social franchising projects in Africa and Asia.These projects incorporate almost 1,100 social franchisees, and from January to

August 2010 they served over 700,000 men and women.

MSI’s experience has demonstrated that social franchising can provide a stimulusto improving service provision in the private sector as a whole. This supply-sideintervention makes services available that were previously non-existent or low inquality in the private sector. In addition, the availability of a recognisable brand witha reputation for high-quality services can increase clients’ interest in receiving care.



20/3220

MAINTAINING QUALITY

whatever we were doing is either

right or wrong. But now that we

have done this training, we are

more condent and it has helpedus a lot.” Voucher provider,


Training and accreditation istherefore the rst step to ensuringa high-quality service.

3.2 Continual quality auditsand checks

CHALLENGES TO PROVIDING

A HIGH-QUALITY SERVICE

Challenges identied by programme

teams include:

• high turnover of staff in healthfacilities can result in low-qualityservices and sub-standarddocumentation

• lack of stock/government supplies

• referral mechanisms, includinggovernment hospitals, can bebureaucratic and take a long time.

All three programmes undertake

multiple checks to ensure thatquality is maintained at participatingservice providers. Actual randomspot checks at the facility playa central role. In addition, clientsatisfaction surveys, mystery clientsurveys and analysing claims datafor correct diagnostics have beenfound to be useful tools. Althoughinternal quality assurance systemsneed to be in place, all threeprogrammes have recognised the

importance to including externalevaluations as well.

As the voucher managementagency, MSI undertakes qualityaudits to ensure that services meetexpected clinical standards in allthree countries (Uganda, Pakistanand Sierra Leone). In Uganda, theaudit tool is a simplied versionof the tests that were used at theaccreditation stage. This allowsthe project team to estimatewhether or not quality standards atindividual facilities have improved,stayed the same or declined. Forexample, at the pre-test phase, ofseven providers, ve had improved

and two had declined in quality.Problem areas ranged from minorissues, such as irregular personnelhours, to major issues, such aspoor or non-existent laboratoryservices. Following a minor

negative quality assessment,service providers are given achance to improve or else faceexclusion from the programme. Formajor quality issues, facilities arefurther investigated and may beexcluded, depending on the degreeof deviation.25

Observing client-providerinteractions has also proved to behighly useful in assessing quality.

In Uganda, MSI systematicallyobserves service providers asthey interact with mothers. In onehighly rural area, the team foundthat newly hired providers wereinexperienced and not technicallycompetent. MSI subsequentlyworked with them to increase thegeneral skills of the staff and toimprove the quality of the wholefacility.25 In addition to internalquality checks, in Pakistan, MSIcontracted an external group to

undertake a quality clinical audit.This helped to ensure that clinicalpractice met all of MSI’s standards.In some cases, individual providerswere not meeting the standardsand remedial action was taken.26 The Pakistan programme alsoundertook client exit interviewsin order to gauge their views onquality. The latest 2010 survey20 suggests that 98.6% of newSuraj clients (franchise clients)

and 100% of existing Suraj clientswould recommend the facility to afriend. In terms of quality, clientswere particularly satised by thefriendliness of the service provider,with a mean score of 4.7 out of 5for the Suraj clients.

The voucher programme in SierraLeone is still very new, but MSI iscurrently undertaking an overallevaluation of the scheme. This willinclude exit interviews, monitoringthe voucher distribution process, therates of redemption and acceptabilityof vouchers in order to assess theoverall effectiveness of the programmein reaching the underserved.

INNOVATIVE WAYS TO

CHECK QUALITY: CHECKING

DIAGNOSES

One way of indirectly assessing thequality of care is to analyse routinelycollected claims data to see the

extent to which the providers areprescribing the correct treatment oroffering adequate family planningchoice. This approach assumesthat provider knowledge is relatedto healthcare quality and has beenused In Uganda by researchers tocheck if STIs are being correctlydiagnosed and treated.27 Byanalysing over 19,000 patient visits,Bellows et al27 found that 79% ofbalantis cases were correctly treated,compared with 98% of gonorrhoeacases. The overall numbers mask

variation between providers. Although overall it appears that thevouchers are diagnosing and treatingSTIs correctly, there is clearly roomfor some improvement. This type ofanalysis allows MSI to work moreclosely with those providers whomight be in need of more training orlaboratory facilities.

3.3 Referral and follow-upnetworks

As with any reproductive healthservice, it is important to havestrong referral and follow-upmechanisms in place in case ofcomplications or, for example, if thewoman wishes to remove an IUDor implant.

In Uganda, where the vouchersare used for safe deliveries,severe complications requiringhospitalisation do occur

occasionally. MSI has thereforeset up a referral network with localgovernment hospitals. Healthproviders who refer to governmentfacilities are required to pay thehospital bills, and bill the projectwith all relevant documentationattached. Redeemable factorsinclude a ‘mama kit’ (a clean, safeand affordable child delivery kitconsisting of plastic sheet, sterilegloves, razor blades, cord ligature,cotton, sanitary pads, tetracyclineand soap), accommodation, mealsas well as other drugs and suppliesused. Health providers referring toanother comprehensive emergencyobstetric care facility do not have


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MAINTAINING QUALITY

to pay for any services. Thespecialised facility takes immediateresponsibility for the bill. Referralto both government facilities andspecialised facilities involved inthe voucher programme require

the referring health provider to llin a referral form, which is alsoendorsed by the receiving facility.Mothers in emergency casesare given transport/ambulanceservices and the claim is sent tothe reproductive health voucherprogramme for reimbursement.

In terms of family planning, thePakistan programme has setup a somewhat simpler follow-

up mechanism: the marketing

agent gives her number to theclients in case of any questions.In addition, there is a toll-freenumber that is open 24 hours aday, seven days a week for freeadvice. This approach has proved

to be very successful, with 60%of the clients using the follow-upservice, and 68% of the vouchersbeing validated.24 In addition, theclient exit interviews are used tocheck that clients have been givenappropriate information on whatto do in case of a problem or ifthey wish to change their choice offamily planning method. The 2009round of data shows that 95% ofwomen reported that they knew

where to go in case of a problem or

side effect and 100% knew whenand where they needed to go forthe follow-up visit.20

This continuum of care is seen asa distinct advantage of the voucher

programme:

“The Suraj model’s best aspect

is the voucher because people

are very needy and because of

this they get free services and we

guarantee that there will be no

problem and ask them to visit us

if they are having any problems

(after they have had the service).” Female marketing agent,


THE POTENTIAL OF VOUCHERS TO IMPROVE QUALITY THROUGH COMPETITION AND ENTREPRENEURSHIP

The programme managers in Uganda see additional longer term benets in the voucher programme including increasedcompetition between providers, which can in turn increase quality. In Uganda, patients living in rural areas are often faced withfewer options relating to health provision. Claims data from the STI voucher scheme suggested that around 60% of patientsvisited a clinic within 10 kilometres of their village of residence, and 55% of these patients were visiting their nearest clinic. 27

“In some areas, the problem is that we don’t have enough competition so there is a monopoly in service provision.

Competition enhances the quality of service.” Christine Namayanja, Voucher Project Director, Uganda

In addition, anecdotal evidence suggests that some providers use the prots from the vouchers to reinvest into their facilities,

thus improving the quality and access to services overall. As Christine Namayanja reects “Angela is a private provider ofSTI management and safe delivery services, who essentially used her small household to provide basic health services.

Angela joined the voucher programme and used the prots to reinvest into her business, taking on more staff and improvingthe facility. The voucher programme gave her the opportunity to develop her entrepreneurial side, which in turn has led to

more women accessing services. Her monthly clientele for both STDs and safe delivery increased by over 90% leading to the

centre’s income growing by over from $USD 1,000 a month to $USD 2,500.”



22/3222

REDUCING FRAUD

4.1 Approaches toreducing the likelihood offraudulent behaviour

In all three programmes, theprogramme managers have hadto deal with the potential forcorruption and fraud. Their rolehas been to work out systemsto minimise this. In Uganda, theteam has identied four maintypes of fraud which can occur atany stage of the process:

1. Counterfeit voucher fraud: thisinvolves falsifying vouchers andthen redeeming false vouchers.

2. Distribution fraud: this type offraud is two-fold and includesboth fraudulent behaviourbetween provider and distributor,as well as between distributorand client. Distribution fraudleads to vouchers being claimedfor services that never occurred.

3. Service provision fraud: thistype of fraud includes a rangeof possibilities, from over-charging for drugs to hiringunder-qualied staff to non-compliance and charging extrafees to clients. In this situation,clients were provided with theservice, but either quality wascompromised or the serviceprovider acted fraudulently toincrease prots.

Chapter Four:

Reducing fraud and improving efciency


All voucher programmes are susceptible to fraud. All of the Uganda,

Sierra Leone and Pakistan voucher programmes have had to learn how

to combat fraudulent behaviour.7 This chapter looks at some of the

checks and balances, and systems that the programmes have

experimented with in order to reduce the likelihood of fraud, as well as

to improve the overall efciency of the programme.


23/3223

REDUCING FRAUD

4. Claims processing fraud: thisinvolves fraudulent behaviourwithin the management agencyeither internally or in collaborationwith the service provider. Thismay include siphoning off funds

by falsifying the number of claimsor falsifying the accounts ofvoucher service providers.

Tackling counterfeit vouchers

(voucher fraud)

In all three countries, theunderlying principle for reducingvoucher fraud has been to makethe vouchers as difcult to copy aspossible and also to track voucher

serial numbers so that these canbe cross-checked.

In MSI programmes, voucherscan either have originalwatermarks (as in Sierra Leone)or barcodes (as in Uganda),or unique code numbers (as inPakistan). The watermarks act

as a quick check for counterfeitvouchers, since they are moredifcult to copy than a papervoucher. The barcode is animportant unique identier andhelps to track how vouchersare used. Individual coding andnumbering has been an effectivemethod by which to discouragecounterfeited vouchers.

Validating claims (distribution

fraud)

TIPS FOR CLAIMS PROCESSING

Processing claims should be:

efficient – payments should be›made quickly and providers

should be reimbursed on time

effective – the system should›allow the managing agent tocheck for accuracy and controlfraud and dishonesty.

An essential part of any voucherprogramme is a robust andefcient system to validate claimsand to ensure that the voucher

being redeemed really doesrepresent an individual who wasprovided with a service.

Of the three voucher programmes,the Pakistan programme hasdeveloped the most rigorousvalidation system, which involvesintensive internal checks as wellas contracting external agencies toundertake random spot checks.

The internal validation system isan integral part of the voucherdesign and relies very heavily onthe role of the marketing agent andin-depth physical mapping. Themarketing agent does more than

ZERO TOLERANCE FOR

FRAUDULENT BEHAVIOUR

It is hugely important to communicatezero tolerance and implementpenalties for those found to beacting fraudulently. In Uganda, this

has resulted in some distributorsbeing expelled from the programme.Contracts with distributors whohave charged clients more thanthe recommended price have beenterminated. In other situations,contracts with distributors who havesold vouchers to non-eligible clientshave been terminated and servicesdenied to such clients.

Service providers who have notcomplied with project guidelines,for example by over prescribing,

over billing and offering poor qualitycare, have also had their contractsterminated.

Uganda voucher design with watermark

Figure 3. Voucher design for Pakistan & Uganda

Pakistan voucher design with watermark is as belowDesign of voucher book


24/3224

REDUCING FRAUD

just marketing and distributing thevoucher and is involved in providingcounselling and follow-up care.

The process which is undertaken inPakistan is detailed below:

1. The marketing agent counselsthe potential client and,depending on the contraceptiveneed and socio-economic statusof the woman, either refers herto the Suraj network or offers hera free voucher.

2. The women eligible for thevouchers take the vouchers tothe provider.

3. The provider sends a servicesreport along with redeemedvouchers to the supervisorvia the marketing agents on aweekly basis.

4. The supervisor then validates aminimum 20% of the vouchersusing a systematic randomsampling technique.

5. The supervisor visits the woman in

her household to conrm that theservice was provided as claimed.

6. The agent also checks whetherthere are any concerns orcomplications and encouragesthe woman to return for the free

follow-up examination.

The ongoing support provided bythe marketing agent has led to veryhigh rates of follow-up, with over60% of women returning for the

three-day follow-up examinationand very high levels of clientsatisfaction, as shown through theexit interviews (see 3.2).

Although this approach has beenuseful for multiple purposes, both interms of ensuring a quality serviceand reducing the likelihood of fraud,it is highly resource intensive andthe programme managers are nowconsidering alternative approaches

that are less expensive:

“The marketing agent has [a] key

role in the marketing of family

planning services and the Suraj

brand, distribution of vouchers to

poor clients, addressing myths

and misconceptions, generating

referrals and strong follow up of

mobilized and served clients.” Jamshaid Asghar, Manager Private

Provider Partnership, Pakistan

Regardless of how robust theinternal checks are, the threevoucher programmes havealso found it important to useindependent external agenciesto undertake additional randomchecking. In 2009, the Pakistanprogramme contracted an externalagency to undertake some randomchecking of vouchers.24 The agencyundertook the evaluation across18 districts, randomly selecting a

total of 540 vouchers to follow up.Fieldworkers visited the household(up to two visits) to validate thatthe household and women actuallyexisted. Women were then askedwhether or not they still had theIUD and whether or not they hadreturned for a follow-up visit.

Of the 540 randomly selectedwomen, only 68% were located andtheir voucher use validated. Theremaining women either were notfollowed up because the householdcould not be located (11%) or thewoman could not be located (19%).Unfortunately, the evaluation onlycollected a minimal amount of

information and it is not entirelyclear how many of the womenor the households that could notbe located were in fact due tofraudulent claims. The agencynoted that the main reasons for not

being able to locate the householdwere due to wrong addresses or un-numbered houses. Some womenwere not located due to economicmigration (e.g. they had gone towork in a neighbouring village) orbecause they were working on theland. In Pakistan, the programmeactually marks the households withchalk. This can lead to errors inhousehold identication after thechalk washes away with the rain.

GPS (global positioning system)mapping would be a far moreaccurate way to locate householdsand is something that theprogramme is now considering.

Checking that quality is

maintained

As outlined in Chapter Three, allthree programmes employ a widearray of options to ensure thatquality is maintained. Random

and unexpected quality audits areused across the countries, as aremystery client interviews. Theseare all explained in more detail inChapter Three.

In Uganda, laboratory practice isthe most challenging area of thevoucher programme. Factors thathave affected laboratory qualityinclude: bad storage of reagents;under-qualied staff; and lack of

continuous medical education. Onthe safe delivery project, healthproviders who were not complyingwith project guidelines, lack ofqualied personnel (affected byhigh staff turnover) and thosewhose facilities and serviceswere found to deteriorate wereterminated. Since the beginningof the voucher programme, MarieStopes Uganda have terminatedthe contracts of seven providers.In the pilot project, ve providerswere terminated and three droppedout due to signicant losses inreimbursements because theywere not following guidelines.

EXAMPLES OF FRAUD FOUND

IN THE VOUCHER SCHEMES IN

UGANDA:

• providers purchase vouchers anduse them to make claims for non-existent clients

• voucher distributors form analliance with providers to providevouchers and agree fake namesand addresses to allow providersto make fake claims and pay thedistributor a percentage

• clients and providers make a dealto claim voucher reimbursementwithout service provision

• providers hand in faked claims

• over-servicing or inappropriateservice provision

• black market trade in vouchers.


25/3225

REDUCING FRAUD

Claims processing

All three countries have investedheavily in developing robust internal

control systems in order to reducethe likelihood of fraud. Basedon both successes and failures,the three programmes identifythe following key elements to asuccessful internal control system:

cheques, payments and›vouchers need to be approvedby authorised signatories inadvance of payment

there are clear roles and›

responsibilities in the cycle forapproving payments

vouchers, invoices and›supporting documents are wellstreamlined in order to reducethe possibility of fraud.

Choice and differential

reimbursement for family

planning vouchers

In many countries around theworld, women and men are notable to access the full range ofcontraceptive options. In particular,long-acting and permanentmethods of contraception remainprohibitively expensive, in boththe public and private sectors,especially for poor people. Familyplanning vouchers are perhapspart of the answer.

Vouchers are often funded as anintermediate step towards socialinsurance schemes. Vouchers cantherefore be viewed through thesame lens as USAID-supportedhealth insurance or social

insurance programmes. In healthinsurance, including Medicareand many private insuranceschemes in the US, contraceptives

are often not reimbursed at all.When contraceptive methods arereimbursed by health or socialinsurance programmes or by hostgovernments, including in theUS or the UK’s National HealthService, they are reimbursed atdifferential rates to providers,based on the provider’s direct,indirect and commodity costs,complexity of the service,etc. Reimbursing providers atdifferential rates is done so that

providers are not biased towardsthe use of one method over theother, thus protecting informedchoice and consent.

It can therefore be importantto reimburse for the provisionof family planning services atdifferential rates, or to reimburseonly one or a few more complex,expensive or underutilised familyplanning services. Vouchers are

less likely to reimburse other,inexpensive and easy-to-providemethods such as condoms or oralcontraceptives.

KEY LESSONS LEARNED: TRACKING AND FOLLOWING CLIENTS

invest in strong internal M&E systems›

train staff extensively on data collection to improve the quality of data›

pilot the household and individual indicators to address any ambiguities›or flaws early on

use GPS to locate households more accurately›

use text messaging to contact women directly.›

USING NATIONAL ID CARDS TO

VALIDATE VOUCHERS

In Sierra Leone, checking identitycards (ID cards) is one way forthe programme to counteract thepotential of falsied claims as theycan check that the woman actuallydoes live in the targeted community:

“ID cards in Sierra Leone are verycommon, especially amongst the

younger generations, so this seemed to

act as an effective tool against fraud.” Gillian Eva,

Africa Regional Research Manager, MSI

As the voucher scheme develops,Marie Stopes Sierra Leone is ndingthat some women have been turnedaway because they don’t carry IDcards. They are currently developingalternative approaches in additionto ID cards, such as a local tax cardor a reminder card with a recentpassport picture.

“Women are only given a voucher if

they present their ID card and they

have to have their ID card with them

to redeem the voucher. A number ofwomen have been turned away from

clinic for not having their ID cards.

This might be because: they forgot

it; they lost it; they sold/gave the

voucher to someone else.” Abu Kargbo, Voucher Distributor,

Marie Stopes Sierra Leone

The client must present her IDwhen purchasing and submitting thevoucher. The client’s individual IDnumber will be written on the voucherand the receipt. Once clinics have

sent vouchers back to Marie Stopesfor reimbursement, the voucherswill then be processed against theinformation and ID numbers will becollated by the distributor

©

M a r i e S t o p e s I n t e r n

a t i o n a l / M a r c o V a n H a a l


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REDUCING FRAUD

4.2 The cost andsustainability of voucherprogrammes

IMPORTANCE OF PARTNERSHIP

The three voucher programmes

highlight that strong partnershipwith the local Ministry of Healthis crucial to the long-termsustainability and scaling up of anyvoucher programme. In Uganda,several individuals at the Ministry ofHealth were involved with KFW (thedonor) from the early design phase.The Ministry saw the programmeas an important mechanism forimproving choice and for improvingthe quality standards amongstmostly unregulated privateproviders. One of the key lessons

learnt from the Uganda programmewas the importance of havingchampions within government andto ensure that the programme isaligned with government prioritiesand service provision.

One of the main criticisms levelledat voucher programmes is that theyare expensive to run mainly due tohigher administrative costs.2,7 Asthis report has shown, there is anatural trade-off between setting up

robust systems to ensure qualityand reduce fraudulent behaviour,and the consequent reduction incost-effectiveness. As the Pakistanprogramme demonstrates, it ispossible to set up systems ofinternal validation, but they arehighly resource dependent.

MSI is currently working with theFutures Institute to undertakea cost-effectiveness study in

Pakistan and Uganda. The resultsare expected in early 2011. As aninterim measure, we undertook asimple analysis of cost-per-client inUganda in 2010 and compared theresult with the nding by Bellowsin 2009. In 2009, Ben Bellowsundertook a simple analysis of theMay 2006 to May 2008 data onthe STI voucher programme inUganda.27 This analysis showedthe average cost per client to beUS$53 per patient.27 One year onand an initial analysis of the 2009data shows the cost per client hasreduced to $21 per client visit.xii As

hoped for, the cost per client servedhas reduced as the programmeincreased in scale.

In Pakistan, the estimated cost perIUD insertion was US $7.21 based

on 2009 gures. The project isexpected to expand in 2011 from100 to 170 providers, so it will beimportant to see the impact on costper service.

INNOVATION: SMS FOR A MORE EFFICIENT SERVICE

In Uganda, the voucher programme is being delivered in highly remote areas,which creates a number of challenges in terms of claims processing. First, serviceproviders are often late in submitting their claims, as they wait until they travel tothe main town where the project team is based. This makes it difcult to plan andrespond to claims as there will suddenly be a large number to process. Projectstaff try to overcome this problem by travelling to the service providers to collectthe claims, but this is not cost-efcient – especially if the project is scaled up.

Mobile phone ownership in Uganda dramatically increased after 2000, when itmatched and then overtook xed line subscribers. This is in part due to the cost

of mobile phones greatly reducing and shared ownership increasing. In additionmobile phone costs are increasingly regarded as an alternative to transport costsin rural areas.28 Consequently there are currently over 8.5 million mobile phoneowners in Uganda.29

A PhD student at Berkeley University in California is currently evaluating a pilotproject using mobile phone-based claims submission software with 19 serviceproviders, in which approximately 100 claims were submitted to a secure web-based database from mobile phones.30 Although only at an initial pilot stage,m-health technology offers a huge potential for more efcient claims processing.

In addition, Marie Stopes Uganda is using mobile phones to improvecommunication with the service providers. The project team has set up a web-based SMS system that allows one person to send text messages via a computer

to all the service providers. Outgoing messages include reminders on qualityissues and notices on when claims are ready to be picked up. Service providerscan then respond with their own queries whereby messages are charged at alocal network fee.

xii This estimate is based on dividing the total project expenditure for the 2009 STI programme (estimated at 30% of total voucher programme, including safemotherhood), subtracting voucher income and dividing by the number of clients. This is comparable to the approach taken by Bellow et al.31



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CONCLUSIONS

Conclusions and recommendations


Access to affordable and safe reproductive and sexual healthcare saves

lives and empowers women the world over. Public health systems in

developing countries face huge problems in meeting the health needs

of their populations. Most countries have developed comprehensive

national health strategies and plans with corresponding goals, and have

also signed up to ambitious international targets, such as the Millennium

Development Goals. However, few countries are meeting these targets

through their current health systems, which are based largely on supply-

side subsidies, delivered through a network of publicly-owned and

operated health facilities.


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CONCLUSIONS

Voucher schemes have increasedthe power and ability to provideaccess to health services tothe hardest-to-reach groups.Vouchers are more targeted thantraditional approaches to health

service delivery. They respond tothe fact that the hardest-to-reachare often the poorest people whocannot afford services. Vouchersalso work with the private sector,which is the main provider ofhealth services to the poor inmany developing countries.

This report has emphasised theinnovative and effective ways inwhich MSI has been experimenting

with voucher programmes inorder to meet the unmet need ofthe poorest of the poor. In SierraLeone, Uganda and Pakistan,MSI voucher programmes arehaving a real impact on the livesof tens of thousands of womenand men. In Uganda, where theprogramme is most mature, morethan 61,000 men and womenhave been reached through thevoucher programme,xiii and as theprogramme evolves, the cost per

service provided has reduced fromUS $53 to $21.27

The three programmes vary acrosscountries – both through the rangeof services offered and the wayeach model tackles commonchallenges such as assuring qualityor targeting the poorest of the poor.Cutting across all three programmeshowever, there are some clearlessons. For example, all three

programmes have successfullydeveloped poverty targetingstrategies that are both evidence-based and avoid being too resource-heavy as there is an intrinsic pay-offbetween a more robust systemto check eligibility and prohibitivecosts of undertaking a rigorousassessment. These prohibitivecosts escalate once a programmestarts operating at scale. Ultimately,there is no one approach to povertytargeting that works everywhere.The approach will need to beadapted depending on whether thecontext is urban or rural.

The role of a community oreld based marketing agent ispivotal. These local communitymembers do much more thansimply distribute the vouchers.They also help to raise awareness

about reproductive health issues,thus breaking down myths andmisconceptions. In Pakistan, theyalso play a role in ensuring acontinuum of care, visiting eachwoman after she has used thevoucher to check that she is welland to encourage her to return forthe follow-up visit.

Through learning and change,the MSI voucher programmes

have developed systems ofquality assurance. The mainways in which the vouchermanagement agency can assurequality is by providing training andaccreditation, undertaking continualquality audits and checks (internaland external) and setting up andensuring follow-up and referralnetworks. All three programmesgo further than just assuring qualityby also playing a role in improvingquality standards.

There are a number of ways tocheck that quality is maintainedat participating service providers. Actual random spot checks at thefacility will always play a centralrole. In addition, client satisfactionsurveys, mystery client surveys andanalysing claims data for correctdiagnostics are all useful tools.

Although internal quality assurance

systems need to be in place, itis always important to includeexternal evaluations too.

It is clear that the programmemanagers recognise that thereis always potential for corruptionand fraud. Their role is to work outsystems to minimise this. Fraudcan occur at any stage of theprocess but can be reduced bysetting up clear systems of vouchervalidation and strong delineatedsystems for claims processing.Sanctions are an important part ofcontracts and

are applied when qualitystandards and specications arenot met over a dened period oftime. These may take the formof simple warnings, and mayproceed to compulsory training,

additional monitoring of qualityimprovements, and eventuallyexclusion from the programme.

Ultimately, administering a voucherprogramme is more complexand resource intensive thansimply providing free servicesindiscriminately. However, thecommon challenges can beovercome, which means thatservices can be successfully

targeted. MSI is still developing itsmodel into best practice. Over thenext year, we will be undertakingmore in-depth evaluations of eachof the three models documentedin this report. Although only aninitial rst stepping stone, wehope that this report has beenuseful in highlighting some ofthe successes and innovationsof voucher programmes and thatit will inspire other partners torealise the potential of vouchers to

reach those who were previouslyunreachable.

Recommendations forprogramme managers:

develop a strong evidence-›based approach to targetingvouchers at poor individuals orcommunities

ensure that checks and balances›

are in place to ensure thatvouchers are really being usedby poor people

invest in M&E systems in order to›track clients, impact and serviceprovision

involve local community›members in marketing anddistributing the vouchers

set up robust yet simple systems›of quality assurance. Definerealistic accreditation standardsto ensure sufficient providers

xiii Based on total number of vouchers redeemed as of August 2010.


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CONCLUSIONS

select the best providers, drop›the worst performers and admitnew providers

define detailed quality›specifications, so providers knowexactly what is expected

develop clear performance›indicators for monitoring

use the accreditation and›training process to ensure thatall providers reach a minimumstandard of quality

quality specifications must be›included in the contract thatgoverns the partnership and arespecific to the services to beprovided

undertake a range of M&E›activities to check that quality ismaintained

work with service providers that›standards

ensure that fraud detection,›and the corresponding frauddetection instruments, areincorporated into the monitoringand evaluation (M&E) framework:both for routine M&E, and forad hoc

Productive Health From Promise to Practice

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