Can vouchers help move health systems toward universal health coverage? Ben Bellows GIC Forum on Health and Social Protection 27 August 2013
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
• 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.
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)?
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How universal can vouchers really be?
Despite growing evidence for vouchers’ impressive 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 WHO’s ‘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 possiblexi. 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 family planning voucher programmes in Korea and Taiwan in the 60s-90s. Even among targeted voucher programmes, some are being operated on a huge scale: the Chiranjeevi Yohana scheme in Gujarat, India, which is targeted to the poor, is a case in point. Vouchers don’t have to be targeted to specific services either: vouchers for migrant farm workers in the US cover all types of services with a maximum reimbursement levelxii. This sort of voucher programme illustrates very clearly how vouchers and insurance are actually on the same spectrum, as noted by Gorter et al (2013)xiii. A voucher scheme in Tanzania is located even further along that spectrum: vouchers distributed to pregnant women entitle the mother and her baby to full health insurance during the baby’s infancy, while the rest of the family gains entitlement to partial health insurancexiv.
However, most voucher schemes do target particular groups, and/or provide entitlement to only a few services. Far from being contradictory to UHC, targeting vouchers both in terms of services and population groups could actually help even well-established UHC systems avoid common pitfalls.
Pitfall 1: Social Health Insurance can emphasise curative care at the expense of public health and preventative care
Because the first aim of Social Health Insurance is to prevent catastrophic health expenditure, some fledgling insurance schemes start by covering expensive inpatient services only, excluding outpatient, primary and preventative services from the benefit package (e.g. India, Kenya, Philippines)xv. In addition, individuals in any system (whether SHI or input-based) may under-consume public and preventative health care if left to their own devices. This is because some of the risks of not seeking care, such as infecting others, as well as the future costs of illness, are borne by others. In either of those situations, vouchers can serve as a useful addition to the prevailing health financing approach, thereby ensuring that preventive services are appropriately emphasised. Vouchers are often used for preventive services, most notably for family planning, but also for immunisation (Cambodia and Armenia), and cervical and breast cancer screening (Nicaragua, Vietnam)xvi.
Figure 1: WHO's Universal Health Coverage 'Cube'
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
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
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
Number of active reproductive health voucher programs
0
5
10
15
20
25
30
Small (<$250k /yr)
Medium ($250k-$1m /yr)
Large (>$1m /yr)
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
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)
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)
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
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 2 rounds of household
surveys o 4 voucher and 3 non-
voucher sites o 5 km radius of facilities
(VSP and non-VSP) Births within two years
before survey o 2010-11: 962 births among
2,933 women 15-49 years o 2012: 1,494 births among
3,094 women 15-49 years
Analysis
• Cross tabulation with Chi-square tests • births by place of delivery over time
• Multilevel random-intercept logit analysis 𝑙𝑜𝑔𝑖𝑡 (𝜋𝑖𝑗𝑘)= 𝑋𝑖𝑗𝑘β + µ𝑗𝑘
• 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
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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<0.01 p<0.01 p=0.59
Change in place of delivery
Outcome 2006 voucher arm
2010-11 voucher arm
Comparison arm
Facility delivery
2.04** (1.40-2.98)
1.72** (1.22-2.43)
1.32 (0.96-1.81)
Home delivery 0.53** (0.36-0.78)
0.61** (0.43-0.85)
0.75 (0.54-1.03)
Adjusted odds ratios
• Changes consistent with increased use of vouchers by respondents • 2006 voucher arm: 20% -> 43% • 2010-11 voucher arm: 11% -> 45% • Comparison arm: 0% in both rounds
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
Study #2, Supply: Facility use of reimbursements
• Cross sectional data from 77 accredited facilities • Retrospective measurement of how accredited facilities allocated revenues across six standard cost categories for phase 1 (2006-‐2008) and phase 2 (2008-‐2011)
• A structured questionnaire sent to accredited facilities
• 88% response rate achieved • Responses analyzed to show percentages of revenue used in standard accounting categories
Use of revenue by category in Phase 2
9% 6%
33% 35%
11% 7%
0% 5%
10% 15% 20% 25% 30% 35% 40%
Revenue source before vouchers program
Prior to the GoK Voucher program 81% of the facili7es reported that following the launch of the
voucher program, the voucher program has been their main revenue.
Revenue Source
Public Facilities
Private Facilities
FBOs
Government 50% 0 0 Self-‐generated revenue
31% 57% 53%
Bank Loans 0 43% 0 Donors 19% 0 37%
Facilities also reported…
Challenges in accessing and purchasing medical and non-‐medical supplies.
Voucher revenue used to: 1. Cover the financing shorDall for purchases 2. Increase capacity and provide more services 3. Improve service quality and increase pa7ent volumes/
bed capacity Flexibility in using revenue may help overcome perennial
problems of centrally managed, public sector supply and commodity constraints and private sector financing gaps to provide beMer healthcare services.
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?
3
How universal can vouchers really be?
Despite growing evidence for vouchers’ impressive 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 WHO’s ‘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 possiblexi. 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 family planning voucher programmes in Korea and Taiwan in the 60s-90s. Even among targeted voucher programmes, some are being operated on a huge scale: the Chiranjeevi Yohana scheme in Gujarat, India, which is targeted to the poor, is a case in point. Vouchers don’t have to be targeted to specific services either: vouchers for migrant farm workers in the US cover all types of services with a maximum reimbursement levelxii. This sort of voucher programme illustrates very clearly how vouchers and insurance are actually on the same spectrum, as noted by Gorter et al (2013)xiii. A voucher scheme in Tanzania is located even further along that spectrum: vouchers distributed to pregnant women entitle the mother and her baby to full health insurance during the baby’s infancy, while the rest of the family gains entitlement to partial health insurancexiv.
However, most voucher schemes do target particular groups, and/or provide entitlement to only a few services. Far from being contradictory to UHC, targeting vouchers both in terms of services and population groups could actually help even well-established UHC systems avoid common pitfalls.
Pitfall 1: Social Health Insurance can emphasise curative care at the expense of public health and preventative care
Because the first aim of Social Health Insurance is to prevent catastrophic health expenditure, some fledgling insurance schemes start by covering expensive inpatient services only, excluding outpatient, primary and preventative services from the benefit package (e.g. India, Kenya, Philippines)xv. In addition, individuals in any system (whether SHI or input-based) may under-consume public and preventative health care if left to their own devices. This is because some of the risks of not seeking care, such as infecting others, as well as the future costs of illness, are borne by others. In either of those situations, vouchers can serve as a useful addition to the prevailing health financing approach, thereby ensuring that preventive services are appropriately emphasised. Vouchers are often used for preventive services, most notably for family planning, but also for immunisation (Cambodia and Armenia), and cervical and breast cancer screening (Nicaragua, Vietnam)xvi.
Figure 1: WHO's Universal Health Coverage 'Cube'
US$ millions 70% coverage of 2 lowest quintiles
2013 2014 2015
Service delivery cost 23 29 32
Management cost (15-‐20%) 3 6 6
Total cost: Maternal voucher 27 35 38
% MOH 2011-‐12 budget $813m 3.3% 4.3% 4.7%
Family planning service cost 16 17 20
Management cost (15-‐20%) 3 3 3
Total cost: FP voucher 19 20 22
% MOH 2011-‐12 budget $813m 2.3% 2.5% 2.7%
Think like a demographer. An incremental allocation could take vouchers to scale
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 (“patient’s 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
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
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
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