can vouchers help move health systems toward universal health coverage?

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Universal health coverage is an aspirational goal "to ensure that all people obtain the health services they need without suffering financial hardship when paying for them." To move toward greater health coverage, low-income countries can foster health systems that increase utilization, improve scope of services, and reduce financial costs to care. Voucher programs operate on both the demand and supply sides to target subsidies to beneficiaries, who in the absence of the subsidy, would likely not afford the healthcare. Governments that create these programs and take them to scale can expect to see greater utilization of priority health services by disadvantaged and can protect low-income populations from catastrophic health expenditure. As national risk pools mature, these voucher programs can become the foundation for larger, more comprehensive health purchasing agencies that cover the whole population with high quality, low cost healthcare.

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  • 1. Can vouchers help move health systems toward universal health coverage? Ben Bellows GIC Forum on Health and Social Protection 27 August 2013

2. Problem: inequality within country "Countries across Africa [and Asia] are becoming richer but whole sections of society are being left behind.... The current pattern of trickle-down growth is leaving too many people in poverty, too many children hungry and too many young people without jobs." - Africa Progress Panel, May 2012 3. Of 12 MNH interventions in a review of public data across 54 countries, family planning was the third most inequitable *Barros, A. J. D., Ronsmans, C., et al. (2012). Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries . Lancet, 379(9822), 1225-33. 4. constraints^3 to financing UHC in a finite universe Trade-offs in three dimensions 1. Utilization: expand population covered? 2. Scope: expand health services offered? 3. Financial protection: increase size of subsidies per service (or improve regulation of informal charges)? How universal can vouchers really be? Despite growing evidence for vouchers mpressive impact in terms of equity, financial protection and quality of care, they remain for now a specific tool to enable underserved groups to access priority services. However the WHOs cube frames progress towards UHC in terms of the share of people, services and costs covered, with a focus on growing these three dimensions as far as possible xi . Given this understanding of UHC, how important can vouchers contribution to UHC really be? The first point to remember is that vouchers do not have to be targeted. For example, all families were eligible for the wildly successful Pitfall 1: Social Health Insurance can Figure 1: WHO's Universal Health Coverage 'Cube' 5. Financing trade-offs Finance movement toward UHC either from a greater budget allocation or greater efficiency Interventions that generate greatest efficiency will likely operate on supply & demand 6. Voucher functions (management) Decide to government-run, contract-out, or franchise Conduct provider administrative & clinical training (i.e. CMEs) Design & maintain claims processing & fraud control Monitor costs, utilization, quality Offer credit to facilities Facility Accredited? Clinical quality? Competition? Reimbursement rates? Client Poverty status & need? Voucher is free or fee? Which services offered? Program design & functions Objective reach beneficiaries who in the absence of subsidy would not have sought equivalent care 7. What can vouchers do & where are the gaps in knowledge? Recent review catalogued 40 programs that used vouchers for reproductive health services (excluded TB and coupons for health products) Summarized evidence from multiple studies of 21 voucher programs 8. Number of active reproductive health voucher programs 0 5 10 15 20 25 30 Small ($1m /yr) 9. Program contracts with public & private providers 18 6 10 1 5 0 2 4 6 8 10 12 14 16 18 20 private mostly private mixed mostly public public 10. Outcome type Number of studies Direction of effect & gaps in research Equity or targeting 8 studies Positive effects: inequalities were reduced. Missing: nationally standard measures. Costing 4 studies Positive effects: OOP spending reduced. Missing: cost-effectiveness, administrative-to-service delivery ratio Knowledge 5 studies Positive effects: increased knowledge of important health conditions. Missing: measures of community norms and partner knowledge. Evaluation outcomes (1 of 2) 11. Outcome type Number of studies Direction of effect & gaps in research Utilization 17 studies Positive effects: increased use of ANC, facility deliveries and contraceptives. Missing: Postnatal care. Quality 8 studies Positive effects: improved customer care, infrastructure upgrades. Missing: clinical care scores. Health 8 studies Positive effects: decreases in STI prevalence, fewer stillbirths, fewer unwanted pregnancies Missing: maternal mortality, DALYs averted, CYPs Evaluation outcomes (2 of 2) 12. Prospective studies 2009-2013 Quasi-experimental design for voucher programs about to launch or expand Measure change in: utilization (new users, aggregate use) equity (concentration indices, standard quintiles) quality of care frameworks (Donabedian, Respectful Care, facility investments) out-of-pocket spending on healthcare 13. Data sources: 2 rounds of household surveys 4 voucher & 3 non-voucher sites 5 km radius from voucher & comparison facilities Births within two years before survey 2010-11: 962 births among 2,933 women 15-49 years 2012: 1,494 births among 3,094 women 15-49 years Study #1, Demand: Study of voucher utilization in Kenya Data sources 14. Analysis Cross tabulation with Chi-square tests births by place of delivery over time Multilevel random-intercept logit analysis ()= + Three arm design 2006 voucher arm: respondents within 5km of facilities in program since 2006 2010-11 voucher arm: respondents within 5km of facilities added to program in 2010 & 2011 Comparison arm: respondents within 5 km of non- voucher facilities 14 15. 2006 voucher arm 2011 voucher arm Comparison arm Place of delivery First survey Second survey First survey Second survey First survey Second survey Home 32% 21% 59% 47% 45% 42% Health facility 66% 79% 39% 51% 54% 57% Public facility 45% 49% 32% 36% 41% 44% Private facility 21% 30% 7% 15% 13% 13% p-value p 45% Comparison arm: 0% in both rounds 17. Limitations of analysis Teasing out direct and indirect effects of the program on facility delivery Identification of respondents within specified distances to facilities could affect over or under-estimation of impact Most covariates for multivariate analysis pertain to time of interview Changes in time dependent co-variates could affect access to facilities 18. Study#2,Supply:Facilityuseof reimbursements Crosssectionaldatafrom77accreditedfacilities Retrospectivemeasurementofhowaccredited facilitiesallocatedrevenuesacrosssixstandard costcategoriesforphase1(2006-2008)andphase 2(2008-2011) Astructuredquestionnairesenttoaccredited facilities 88%responserateachieved Responsesanalyzedtoshowpercentagesof revenueusedinstandardaccountingcategories 19. UseofrevenuebycategoryinPhase2 9% 6% 33% 35% 11% 7% 0% 5% 10% 15% 20% 25% 30% 35% 40% 20. Revenuesourcebeforevouchersprogram PriortotheGoKVoucherprogram 81%ofthefacili7esreportedthatfollowingthelaunchofthe voucherprogram,thevoucherprogramhasbeentheir mainrevenue. Revenue Source Public Facilities Private Facilities FBOs Government 50% 0 0 Self-generated revenue 31% 57% 53% BankLoans 0 43% 0 Donors 19% 0 37% 21. Facilitiesalsoreported Challengesinaccessingandpurchasingmedicalandnon- medicalsupplies. Voucherrevenueusedto: 1. CoverthenancingshorDallforpurchases 2. Increasecapacityandprovidemoreservices 3. Improveservicequalityandincreasepa7entvolumes/ bedcapacity Flexibilityinusingrevenuemayhelpovercomeperennial problemsofcentrallymanaged,publicsectorsupplyand commodityconstraintsandprivatesectornancinggaps toprovidebeMerhealthcareservices. 22. In a scaled vouchers strategy that moves us toward UHC, which trade- offs would be less painful than others? Is this a more efficient option p than alternatives?How universal can vouchers really be? Despite growing evidence for vouchers mpressive impact in terms of equity, financial protection and quality of care, they remain for now a specific tool to enable underserved groups to access priority services. However the WHOs cube frames progress towards UHC in terms of the share of people, services and costs covered, with a focus on growing these three dimensions as far as possible xi . Given this understanding of UHC, how important can vouchers contribution to UHC really be? The first point to remember is that vouchers do not have to be targeted. For example, all families were eligible for the wildly successful Pitfall 1: Social Health Insurance can Figure 1: WHO's Universal Health Coverage 'Cube' 23. US$millions 70%coverageof2lowestquintiles 2013 2014 2015 Servicedeliverycost 23 29 32 Managementcost(15-20%) 3 6 6 Totalcost:Maternalvoucher 27 35 38 %MOH2011-12budget$813m 3.3% 4.3% 4.7% Familyplanningservicecost 16 17 20 Managementcost(15-20%) 3 3 3 Totalcost:FPvoucher 19 20 22 %MOH2011-12budget$813m 2.3% 2.5% 2.7% Think like a demographer. An incremental allocation could take vouchers to scale 24. UHC & vouchers - Equity Voucher clients are often identified as poor, with a low likelihood of using care Vouchers educate households to use service, even when the service is free (patients charter) Vouchers can control informal payments Vouchers provide managers with data on eligible households, utilization, and feedback on populations that need extra mobilization Vouchers can be targeted to the poor to pay their insurance premiums 25. UHC & vouchers- Financial protection Voucher clients receive a subsidy and avoid paying out-of-pocket at point-of- care Voucher programs often contract private facilities, which expand access and improve the likelihood that households will avoid OOP 26. UHC & vouchers- Quality of care Accreditation standards screen out underperforming facilities Reimbursements paid conditional on meeting minimum service delivery requirements Quality-adjusted reimbursements are possible 26 27. Thank you RHVouchers.org @benbellows bbellows@popcouncil.org

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