vouchers for health: increasing utilization of facility-based family planning and safe motherhood...

8/8/2019 Vouchers for health: Increasing utilization of facility-based family planning and safe motherhood services in Kenya

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P4PC

aseStudies

Vouchers for health:IncreasIng utIlIzatIonof facIlIty-based famIlyPlannIng and safe

motherhood serVIcesIn Kenya

This case study describes a Kenyan demand- and supply- side pay-for-performance (P4P) scheme that uses vouchers as a means to reduce

maternal and child mortality. Subsidized vouchers are targeted to poor

women, enabling increased access to a range of safe motherhood and

family planning services. Accredited public and private health service

providers are reimbursed for voucher-supported services provided.

Findings show that uptake of safe motherhood vouchers was very

successful; however uptake of family planning vouchers proved more

complex. This case study provides an example of a Government-led

program to increase service utilization and offers lessons for countries

considering implementing similar voucher-driven schemes.

B Bllws, Mahw Hamil, a Fracis K

nside

Ab h P4P CasSis Sris2

Acrms 2

rci3

Backgr 5

Prgram Srcr

a Maagm 9

Prgram Impac 17

mmar 22

Ackwlgms 26

Rfrcs 27


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2 P4P Case Studies - Kenya

ABout tHe P4P CASe StudIeS SeRIeS

Pa-fr-prfrmac (P4P) is a srag ha liks pam rsls. Halh scr sakhlrs, frm iraial rs

gvrm a halh ssm plicmakrs, prgram maagrs,a halh car prvirs icrasigl s P4P as a impra

cmplm ivsig i ips sch as biligs, rgs, a

raiig wh wrkig srgh halh ssms a achiv

h Millim dvlpm Gals (MdGs) a hr args

ha rprs br halh sas fr ppl. B prviig

fiacial icivs ha crag wrk war agr-p

rsls, P4P hlps slv challgs sch as icrasig h qali

f, as wll as accss a s f halh srvics.

Ma vlpig cris ar pilig r scalig p P4P

prgrams m MdGs a hr halh iicars. each

crs xpric wih P4P is iffr, b b sharig

apprachs a lsss lar, all sakhlrs will br

rsa h prcsss a challgs ivlv i P4P

prgram sig, implmai, valai, a scal-p.

this Halh Ssm 20/20 cas s sris, which prfils

maral a chil halh-ri P4P prgrams i cris

i Africa, Asia, a h Amricas, is i hlp hs

cris a rs alra gag i P4P fi- hir

prgrams a hs ha ar cmplaig P4P ap scha prgram as par f hir ffrs srgh hir halh

ssm a imprv halh cms.

Ax ach cas s ar ls ha h cr s i is

P4P prgram. th axs appar i h lcric vrsis

(Cd-RoM a Halh Ssms 20/20 wb si) f h cas s.

Ra eichlr, Ph.d

tchical Avisr, Pa fr Prfrmac

Halh Ssms 20/20 Prjc

ACRonyMSAnC Aaal Car

BtL Bilaral tbal Ligai

FBo Faih-bas orgaizai

FP Famil Plaig

GVR Gr-bas Vilc Rcvr

IGeS Isi fr Gshis Szialfrschg GmbH (Isifr Halh a Scial Rsarch,L.)

IuCd Irari Cracpiv dvic

KdHS Ka dmgraphic a HalhSrv

KfW Grma dvlpm Bak

KMet Ka Mical a ecaialtrs

MoH Ka Miisr f Halh

MtR Mirm Rviw

nCAPd naial Criaig Agc frPplai a dvlpm

nGo ngvrmal orgaizai

nHIF naial Hspial Israc FoBA op-bas Apprach

PnC Psaal Car

PwC PricwarhsCprs

SdP Srvic dlivr Pi

SM Saf Mhrh

tFR tal Frili Ra

VMA Vchr Maagm Agc

VSP Vchr Srvic Prvir


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IntroductIon

this cas s cms a vl halh fiac irvi i Kaha ss vchrs a irc rimbrsm rsrcr icivs

amg pais a halh car prvirs. th vchr givs pais a

larg, prabl cmic sbsi ha h ca ak a accri

facili fr priaal srvics, iclig facili-bas livris a lg-

rm famil plaig (FP) prcs. Prvirs ar rimbrs fr raig

vchr-barig pais accrig a cracall agr saarf car. I h firs w ars f h prgram (J 2006ocbr

2008), mr ha 60,000 wm livr sig h Saf Mhrh

(SM) vchr a h prpri f mrgc bsric srgris

icras ramaicall a crac faciliis. Mr ha 10,000 wm

s h FP vchr accss lg-rm mhs (msl irari

cracpiv vics a bal ligais) frm qalifi mical

prfssials.

th vchr prgram was lach i J 2006 wih 54 crac

pblic, priva, a -prfi prvirs. th iiial prgram arg

hr rral isrics a w rba slms rprsig a al pplai

A man brings his newborn to a clinic to

receive postnatal care services offered

through the Safe Motherhood Voucher (SM).


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f mr ha 3 milli. B ocbr 2008, h prgram ha ra mr

ha 60,000 xpca mhrs a 10,000 iivials skig lg-

rm FP mhs. A sc phas is pla bgi i 2010 wih a

xpa packag f srvics a aiial prvirs i h sam pil

aras.

thr spara vchrs wr vlp ffr : 1) aaal car,

facili-bas livris, a psaal car; 2) mr mhs f

lg rm FP; a 3) gr-bas vilc rcvr (GVR) car.

Alhgh a pplai impac valai was cc i Phas I

(a cmprhsiv valai is big carri i Phas II), vchr

claims aa a faciliis mhl ilizai figrs prvi sm isigh

i pai vlm rig h iiial prjc pri. th Ka vchr

prgram was sccssfl i icrasig facili ilizai, pariclarl wih

rspc h SM prgram. Hwvr, giv h aial fr FP,

icrasig ilizai f h FP srvics i Phas II will b a sigifica

gal f h vchr maagm am.

this cas s f h Ka vchr prgram is bas pblish

rprs, prsal cmmicais, a iral cms ma

availabl h ahrs. Prvis cms prvi sfl backgr

a isighs i h rigis f h prgram a wr wri b

xprs i h Ka Miisr

f Halh (MoH); h naial

Criaig Agc fr Pplai

a dvlpm (nCAPd) a hMiisr f Plaig a naial

dvlpm; cslas frm

h Grma Isi fr Halh

a Scial Rsarch L. (Institut

fr Gesundheits und Sozialforschung

GmbH, IGeS); h Bill & Mlia

Gas Fai; Famil Halh

Iraial a h Pplai

Ccil.

The SM Voucher allowed this mother

to seek proper pre- and postnatal

care.


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MAteRnAL MoRtALIty And

FAMILy PLAnnInG In KenyA

th Ka halh car ssm is i a ssai crisis, vi ipr pplai halh cms a rilizai f xisig

faciliis. Rprciv halh srvics ar a barmr f halh ssm

prfrmac a ar a sigifica firs pi f cac fr h majrif al wm i h cr. Alhgh a high prcag (mr ha

80 prc) f prga wm sk aaal car (AnC), fwr ha

half livr i a halh facili, ma bcas h ca affr h css

f srvic r raspr, r ar iscrag b h lw srvic qali.

Ka saw a ssai a rlaivl imprssiv fall i h al frili

ra (tFR) frm 8.1 (197578) 4.7 (199597); hwvr, accrig

h 2003 Ka dmgraphic a Halh Srv (KdHS), h icrass

i cracpiv prvalc sall a 39 prc (19982003) a

h tFR rs 4.9 i 2003 (Cral Bra f Saisics al. 2004).

ths prcags ar sigifica i a grwig pplai, a Kaspplai grw rghl 25 prc bw 2000 a 2008. A prs,

hr ar apprximal 8 milli wm ag 1549 ars, a his

mbr will grw 10.5 milli r mr b 2015. th 2003 KdHS

sima h mia ag a firs marriag b 17 ars fr wm

wih cai, a 19 ars fr wm wih a primar cai.

Fr-fr prc f crrl marri wm wa mr chilr

a 79 prc f wm wih six r mr chilr wa mr.

bacKground


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y h prvalc f vlar srilizai, irari cracpiv

vic (IuCd), a ral cracpiv s is fallig, whil h s

f lg-acig hrmal mhs has ris slighl, kpig vrall

prvalc f mr FP s csa a 31 prc.

daa maral halh iicars i Ka ar pr. Rc aial

srvs hav sima ha 414 wm i frm chilbirh-rla

cass pr 100,000 liv birhs (KdHS 2003). ua livr is

f h gras risk facrs fr maral mrali a mrbii (Gill

al. 2007). of birhs rpr i h 2003 KdHS, l 40 prc wr

livr i a halh facili. th lack f rai mical assisac rig

livr jparizs h livs f bh mhr a wbr. unICeF

sima ha hr ar 80 ifa ahs (r 1 ar l) pr 1,000

liv birhs a 121 ahs f chilr r 5 ars f ag pr 1,000 liv

birhs (unICeF 2007). Lw cracpiv s a h crrla high

tFR rsls i iaqa birh spacig, which cribs maral

mrali a ls prcivi as g wm ar pll awa frm

caial ppriis a cmic acivi a a arl ag.

Giv h rapi grwh i h mbr f fril wm a h ris

i h tFR, i is pssibl ha lss w sragis ar ap, mr

Ka wm will i frm prgac, chilbirh, a saf abri

i h cmig ca ha i a prir 10-ar pri i h hisr f

h cr. Fr vr wma wh is i chilbirh, p 20 wm

sffr mrbiiis, f wih svr mical a scial csqcs.

Wih accss srgical rpair, a faal fisla ca lav a wmaici, which smims rsls i abam b hr hsba

a famil (Vlz al., 2007). Ifrili ca hav similar csqcs.

Gr-bas vilc agais wm als is a sigifica prblm i

Ka. th 2003 KdHS f high prpris f marri wm a

ivrc r spara wm xpric iffr frms f vilc

b hir crr r las hsbas. th ms cmm frm f spsal

vilc was slappig r arm wisig, which ha b xpric b

-hir f wm. th KdHS f ha 23 prc f vr-marri

wm ha vr b psh, shak, r hrw b a hsba; 17

prc ha b pch; a 11 prc ha b kick r ragg.

th KdHS ccl ha marial rap appar b cmm, wih

15 prc f marri wm a spara r ivrc wm

rprig havig xpric frc sxal ircrs; 12 prc

rpr his xpric i h 12 mhs prcig h srv (KdHS

2003).


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deVeLoPMent And LAunCH oF

tHe VouCHeR PRoGRAM

t arss hs maral halh a gr vilc pririis, h

Grma dvlpm Bak (KfW) prvi sppr fr a vchrprgram sbsiiz saf mhrh, FP, a GVR srvics. Plaig

h vchr srvics k svral ars frm ccp prgram

lach. Iiial cslais k plac i la 2003. A chical assisac

missi Ka i arl 2004 brgh ghr parrs frm h

gvrm f Ka, rs, gvrmal rgaizais (nGos),

a faih-bas rgaizais (FBos) i a wrkshp whr h vchr

ccp was irc a iscss. Aciv sakhlrs i h

vchr prgram ccpalizai icl KfW, h Africa Pplai

a Halh Rsarch Cr, h Ka Gvrm divisi f

Rprciv Halh, h nCAPd, h Ka Mical a ecaialtrs, h MoH, h naial Hspial Israc F (nHIF), h

Pplai Ccil, PricwarhsCprs (PwC), a srvic

prvirs.

th rsls f h 2004 chical missi wr prs

i a fasibili rpr h rs a nCAPd ha

prs pis a rcmmais fr h sig,

css, a rgaizaial srcr f h prps

vchr prgram (Griffih al. 2004). th rpr als

prs rcmmais ivsms i ifrmai

ssms, fiacial ssms, capaci vlpm, markig

sragis, a valai capabiliis. Cs simas wr

als icl, b mifi as plas wr clarifi i 2005

a 2006.

evs wihi Ka a h im hlp riv h

vchr aga. Parliam was csirig lgislai

cra a aial scial halh israc f a

h vchr ccp was viw b sm Ka

plicmakrs as a sfl ml fr crac srvics

a prvir rimbrsm. th Miisr f Plaig anaial dvlpm, hrgh h nCAPd, als s

gai sigifica xpric giv is k rl i h sig

a implmai f h vchr prgram.

I 2005, h gvrm f Ka mbark a

prfrmac-bas rprciv halh prgram

Through the FP Voucher, women can

receive FP counseling and services

at local providers participating in the

voucher scheme.


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iciviz accss wms rprciv halh car. th

gvrm rmi ha piall ffciv mas imprv

rprciv halh cms was mpwr pais wih a vchr

accss car frm apprv prvirs wh wl b rimbrs a

pr-pai basis. I vlp a sigl prgram wih spara vchrsfr FP a SM srvics, h lar f which icl aaal car a

accss a qalifi halh wrkr rig livr. A hir vchr

allw clis accss GVR srvics iiiall frm nairbi Wms

Hspial; lar his was x hr accri hspials i h

prjc aras. th vchr srvics wr lach i J 2006 b h

nCAPd i h rral isrics f Kism, Kii, a Kiamb, as wll as

h nairbi ifrmal slms f Viwaai a Krgch. tghr,

hs aras hav a al pplai f apprximal 3 milli.

drig h plaig sag, aspcs f prgram sig a vchr

pai pplais rw sigifica chags. Iiial pial

prgram bficiaris rag acrss svral high-priri pplais

frm xpca mhrs m a wm skig FP srvics

iivials skig HIV cslig a sig. th cisi

prvi crac SM srvics lw-icm wm was ma afr

rviwig pimilgic aa iif m a afr cslig

sakhlrs rmi if h cmbiai f vchrs a cracs

wl b a sfl lvr rc maral mrbii a mrali.

th SM vchr as fiall implm ils h sr fr

AnC visis, a livr visi, a psaal car (PnC) wihi sixwks afr livr a a crac facili. Cmplica livris,

ha fr xampl ra xcssiv bl lss r prvi srgr, ar

rimbrs a ab fr ims h ra fr rmal livris ($292

vrss $70). PnC s crrl icl malaria prphlaxis, b

s ivlv basic vacciai fr h ifa.

th FP vchr ils h sr a

f svral mr cracpiv mhs:

bilaral bal ligai (BtL), vascm,

hrm-bas implas, a IuCds. th

GVR vchr ils h sr micalxamiai, ram, a cslig.

th SM a FP vchrs ar availabl frm

crac vchr isribrs praig i

siga pblic vs. th GVR vchr is

isrib l a crac faciliis rahr

ha a hir-par isribrs, h

pricabili f h v.

Facilities were selected to participate i

the voucher scheme as voucher service

providers if they could demonstrate th

their staff was qualified and competent

the delivery of healthcare services.


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PRoGRAM MAnAGeMent

Figr 1 scribs h rgaizaial srcr f h vchr prgrami rms f majr fcis a h acrs rspsibl. As is am

implis, h vchr maagm agc (VMA) is h rgaizai

rspsibl fr maagig h vchr prgram vrall. I Ka, VMA

fcis wr iiiall ivi bw h fiacial srvics cmpa

PwC a h -prfi Pplai Ccil, which wrks iraiall

isss ar pplai a rprciv halh. th nHIF was

chs pla a rl prviig accriai a qali assrac

srvics, which wl crib h mirig a valai

b PwC.

Program structureand management


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11/28


PRoVIdeR SeLeCtIon And ACCRedItAtIon

Fif-fr halh faciliis wr crac as vchr srvic prvirs

(VSPs), a h nGo Mari Sps Ka prvi rach FP srvics

i all h prjc sis. Facili paricipai vari b rgi a p fprvir (tabl 1). Lss ha 40 prc f h VSPs wr gvrm

faciliis.

table 1: DistributiOn OF COntraCteD

FaCilities by lOCatiOn anD tyPe OF PrOViDer,

OCtOber 2007

s Pc Pv FbO ngO to

Kism 7 6 3 2 18

Kiamb 11 3 3 0 17

Kii 1 2 4 0 7

nairbi 2 8 0 2 12

tal 21 19 10 4 54

th nHIF maag VSP accriai. Iiiall, ma faciliis wr

crac wih h aim f spprig cmpii a pai chic,

a wih h rsaig ha hir srvic qali wl imprv

vr im. th i was cliva capaci a xpric amg

prvirs a wihi h nHIF, which wl il bfis b h

scp f h vchr prgram.

Accri faciliis ha m h saffig a ifrasrcrrqirms f h vchr prgram. th faciliis wr xpc

hav prprl rai saff wh m aial prfssial saars. All

phsicias, rss, miwivs, pharmaciss, a pblic halh prfssials

ha b rgisr wih hir apprpria prfssial halh ccils,

.g., Ka Mical a dal Praciirs Bar a th nrsig

Ccil. th rgisrai f halh car prvirs a faciliis is

cmplsr (Griffih 2004). I aii, h -gvrmal halh

faciliis acqir a Srvic dlivr Pi (SdP) mbr

frm h MoH s ha h cl rciv gvrm-prvi rgs,

vaccis, a hr mical spplis which h wr il as VSPs.

th mirm rviw (MtR) f h vchr prgram (Mai al. 2008)

f facili praig wih a SdP mbr, which ma ha

i cl rciv vaccis a cracpivs ircl frm h MoH.

Csql, ifas br a his facili ha b rfrr lswhr

fr h BCG vacci fr brclsis. (th Wrl Halh orgaizai

rcmms BCG fr all wbrs i tB-mic aras [Rkha a

Swamiaha 2007]).


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StAndARd oF CARe

Alhgh ri nHIF rviws f facili cmpliac wih h saars

f car wr b s as a basis fr rwig VSP aal cracs,

his was vr implm. As abv, h Pplai Ccilvlp a maal ailig, b prcr, h saars f car a

prviig sampl qali mirig ls (Warr al. 2006) ha wr

hav b s i Phas 1 f h vchr prgram. th ahrs f

his cas s rviw h fllwig ls:

z Accriai Maal

z Criria fr Vchr Srvic Prvir Slci

z Qali Assrac Mhl Mirig evalai tl

z

Qarrl Qali Rviw tl

z Qarrl Sppr Sprvisr tl

z Mhl Cli exi evalai Frm

Alhgh h facili saar-f-car rviws i ak plac, h

qali f halh car prvisi i pblic faciliis cl b srgh

hrgh priic raiig bs pracics h MoH givs all pblic

prvirs (i a f h vchr prgram) priic raiig ha ca

hlp hm ar ciig mical cai (CMe) cris.

Fr priva prvirs i h vchr prgram, hwvr, hr wasihr CMe ppri r rglar facili rviw. th MtR f

priva vchr facili wih implas i sck b saff rai

isr hm, alhgh isri is a

mir srgical prcr. A sli

ha sms appar maa mr

raiig is wih prblms: ri

mical raiig has clar cs implicais

fr priva VSPs. Allwig saff a

raiig mas ha h facili will hav

pra wih ha prs/s r g ashr-rm rplacm, a aiial cs.

t crag hs faciliis sppr

saff raiig, h ms b cvic ha

h br-rai saff will hac lg-

rm prcivi (a srvic qali),

wighig h shr-rm cs f raiig.

The SM Voucher helps combat

economic barriers preventing Kenyan

women from receiving safe delivery

services and postnatal care.


13/28


PwC scr claim frms fr cmplss a mical lgic. (S h

claim frm i h Ax A) th claims cl hav prvi a prspciv

h faciliis saar f car. I was clar h ahrs,

hwvr, ha h claims wr masr agais a xplici qali

args r ha hr was v sffici ifrmai rpr hclaims frms masr aspcs f halh car qali.

Alhgh h MtR i iif h prcag f -cmplia

faciliis, i i iif a rag f prblms cr b VSPs rig

cmpl wih h saar f car. of h iaqa pracic was

h rsl f shrcs ak maximiz rimbrsm rv. th

MtR rcmm h s f maagm safgars avi facili

vrcrwig, rs f spplis sch as glvs, a ischarg bfr

pai is ra (Mai al. 2008).

PRICInG And ReIMBuRSeMent

VSPs f all ps pblic, priva, nGo, a FBo rciv p

h maximm rimbrsm ras shw i tabl 2. Ras wr

gia wih ach facili bfr h facili was crac. Grall,

gvrm faciliis wr rimbrs a a lwr ra ha priva s,

bcas h gvrm cvrs majr xpss (saff im a spplis)

i pblic faciliis sparal. ulik i h ugaa vchr prgram, h

Ka vchr prgram cl mak vchr rimbrsms ircl

h VSP, rahr ha h isric halh ffic (Bllws a Hamil

2009).

table 2: maximum reimbursement rates by

serViCe FOr sm, FP, anD gVr VOuChers

Rates for SM services include KSh 1,000 for 4 antenatal visits, about US$3.50

per visit.

Voc vc Ks us$

SM: nrmal livr 5,000 $70

SM: C-sci r hr cmplica livr 21,000 $292

FP: BtL a vascm 3,000 $42

FP: Impla 2,000 $28

FP: IuCd 1,000 $14

GVR Fll cs Fll cs


14/28


th pical rar im fr rimbrsm was 30 as. narl

all priva a FBo prvirs xprss saisfaci wih h sp f

claims prcssig a rimbrsm. n srprisigl, pblic a FBo

faciliis wr vr hsiasic ab h prgram as i rprs

aiial rv abv wha h rciv frm gvrm ars, whras priva prvirs wr mr irs i imprvig

h rimbrsm ams.

Bh h srvic css a fs charg b prvirs vari fr

-vchr pais, accrig a slci f prvir ccrs

pblish i h MtR (Mai al. 2008). this variai was gras fr

C-scis, fr which prvirs charg KSh 12,00030,000 fr -

vchr pais; h vchr prgram rimbrsm fr his srvic

was KSh 21,000. A fw priva prvirs rpr ha hir css fr

cmplica livris xc h rimbrsm am. ohr

prvirs, spciall pblic cliics, wr sr f hir css, a

sbsql h VMA assis hm wih fiacial rcr kpig.

Sm prvirs rpr ha a larg mbr f h claims h

sbmi, i sm cass mr ha a qarr, wr rjc bcas f

icrrc r icmpl ifrmai h claim frm (Mai al. 2008).

ovrall, h vchr prgram sms b havig a psiiv capaci-

bilig ffc i rms f familiarizig prvirs wih h prcss f

rimbrsm a rackig hir xpirs.

ReACHInG uSeRS

Avrisig agc Lw Scaa was crac mark h

vchrs. Markig mhs icl mlimia prsais

a pblic migs, rligis cgrgais, a mark as. Rai

avrisms wr s, b spcific aa ar availabl cvrag

r h mbr f rai sps. Bra imags, slgas, a pri

marials wr vlp. Figr 2 shws prmial psrs fr h

SM a FP srvics.


15/28


Figure 2: POsters FOr saFe mOtherhOOD anD

Family Planning serViCes

PwC sig a pri h vchrs, which wr giv vchr

isribrs. disribrs iifi pr wm i f rprciv

halh srvics a piall ligibl fr vchrs. t rmi

ligibili, h s a pvr graig l (s Ax B) vlp b

MSK ha masr pvr accrig lcall maigfl ccps

lik mbr f mals pr a a hm bilig marials. If h wm

wr f ligibl, h wr allw b a vchr frm h

isribr a h prics f KSh 200 fr h SM vchr a KSh 100 fr

h FP vchr.

Prir h 2006 lach f h vchr prgram, cmmi grps

wr prps as g vchr isribrs. yh a wms grpswr crag sll vchrs prga wm a iivials

skig lg-rm FP pis. As h prgram prgrss i 2007, h

ml appar wrk wll i Kism a Kii isrics b imprpr

r fral vchr sals wr rprl cmm i h nairbi

slms a Kiamb isric. (Spcific mbrs ar availabl.) Vchr

isribrs i h lar aras cmp sll vchrs bcas

h ar a cmmissi vr sal. oc nCAPd iifi h


16/28


lakag, isribr rimbrsm was chag a fix mhl

salar a aal salar b rw if sigifica mbrs f

sal sals wr bsrv. Sp-chcks wr cc a a sampl

f pais hms cfirm ha h pais qalifi as lw icm.

Sch chcks iscrag wispra imprpr sals b rqir aabili fllw p a lca pais, which is cs ffciv a

sfficil larg scal prv all sch cass.

Pais ra vchrs fr srvics a crac prvir faciliis, a

prvirs sbmi claim frms h VMA fr rimbrsm. As

abv, h rimbrsm prcss sall aks ab 30 as frm h

a f sbmissi.

thr ar w aiial pis ab vchr isribi b :

th GVR vchr is fr f charg a, as wih h hr srvics,h prvir is rimbrs prvisl gia ras. this was

maximiz h iciv fr pial clis sk, a VSPs prvi

car. GVR srvic clis f fl sham a cfr a gra al

f scial sigma, v i halh car faciliis, i a halh ssm ha is

largl rspsiv gr vilc. Fwr ha 400 claims hav

b sbmi fr his srvic.

Prchas f h FP vchr is a impra iicai ha h pai

is xrcisig chic sk lg-rm birh crl. Hwvr, hr

is sm ccr i plicmakr a glbal rprciv halh circls

ha gvrm-f FP icivs cmpl pais i chics

h ma rgr. Chargig fr

h vchr is csir

a impra sigal ha h

pai is makig h cisi

frl a is sr ab sig

h srvic.

Local voucher distributors

assess voucher eligibility based

on a poverty grading tool.


17/28


Wh valaig h impac f a vchr prgram, fiv cagris fcms cmml ar csir: pai a prvir kwlg,

srvic qali, facili ilizai, srvic xpirs, a isas

br (prvalc r icic). ths cms ar grall

masr a ihr h facili lvl r, lss cmml, i h gral

pplai, a cmpariss ma bw grps ha rciv h

irvi a similar grps ha i rciv h irvi.

th aa frm h Ka vchr prgram allw fr makig a

pplai impac assssm. Hwvr, a rrspciv facili-lvl

valai is pssibl as PwC has ril cllc facili aa frm

VSPs a pvr scrig irviws b vchr isribrs.

th nCAPd has als rcr vchr a -vchr maral

livris a crac cliics a ca cmpar vchr a -

vchr ilizai rs vr im.

I aii impac valai, prgram maagrs cl s his

grs am f facili aa imprv mirig f prgram

srvic qali a cs ffcivss. Fr xampl, cmbiig -

vchr ilizai wih kw facili css fr -vchr livris

prvis a cs--p rai ha cl h b ircl cmpar

wih vchr livr css.

Pplai impac assssm grall rqirs aa cllc si

f ri vchr prgram prais. I 2006, h nCAPd crac

Program ImPact


18/28


Voc

vc

no-voc Voc t s

SM livris, all 67,259 60,581 51,000 78,635FP, all 5,973 11,296 62,000 25,620

BtL 774 3,954

Vascm 4 5

IuCd 1,805 594

Implas 3,390 6,743

GVR 337 1,000

Micr Cslas cc a basli srv a sig a

framwrk fr mirig a valai. Micr carri a rcrs

rviw a slc crac faciliis a ma rcmmais fr

imprv ifrmai maagm (Mwg a oik 2007). th

fr a pplai impac valai was clar i h plaig sags arcmm a ar i h prgram b h MtR am, b a

valai has b cc.

utILIZAtIon: IMPACt on PAtIentS

th 2004 SM vchr fasibili rpr prps a iiial arg f

100,000 livris i h firs w ars f h prgram. Hwvr, as

plaig prgrss, h fial pr-lach arg, bas h siz f

h sima KfW gra, a sima srvic livr a vrha

css, was rc 51,000 livris. oc h prgram bga,acal ilizai f h vchr far srpass his lwr arg a

spplmal fs wr pa fr h aiial livris.

th vchr prgram rachs sm pri f prga wm wh

prvisl i livr a faciliis bcas f cmic barrirs.

Hwvr, wm ci fac barrirs livrig i halh faciliis

fr xampl, a abrp s f labr a r lack f raspr ha

prv hm frm rachig a facili. th vchr prgram al ma

b gh vrcm h livrig a hm.

I cras h pplari f h SM vchr, ilizai f h FP

vchr srvics was lw; ha is, whil h FP vchr acc fr

rghl w-hirs f all FP srvics prvi a crac faciliis, h

s f FP mhs i gral rmai lwr ha aicipa. Icrasig

ilizai rmais a cral gal f h Ka vchr prgram.

table 3: utilizatiOn by serViCe,

June 2006OCtOber 2008


19/28


Voucher and non-voucher actual patient volume, target patient volume, and voucher

sales, by service. The voucher program accounted for roughly half of all deliveries and

two-thirds of FP services among contracted facilities. However, FP utilization was much

lower than anticipated, and fewer than half of all FP vouchers sold had been used by

October 2008.

o impra ras fr h lw pak f FP vchrs ma b a

xaggra far f si ffcs f mr cracpi mhs. daa

frm h 2003 KdHS, prs i Figr 3, sppr his cclsi.

this implis a fr a srgr caial cmp h FP

vchr markig ffrs. ohr rass fr sig cracpi,

sch as prsal ppsii r rligis prhibii, migh als b

iflc hrgh markig.

Figure 3: maJOr reasOns nOt tO use a mODern

COntraCePtiVe methOD

The most important reasons for respondents under 30 not using modern

contraception are safety concerns, religions prohibition, personal opposition, and the

desire for more children. For respondents older than 30 years, there is less need as

well. Sourcing and access are not major issues for any age group.

Src: 2003 KdHS


20/28


I h prsc f a vchr r hr ma-si sbsi, h firs

pais prchas h vchr ar hs whs ilizai has b

limi sll b cs r accss, a all vchr prgrams ca capr

hs pais. Fr hr pais, rilizai f a srvic ma

b riv b -cmic facrs sch as clral rms r fars fharmfl si ffcs. th aa i Figr 3 iica ha -cmic

facrs ma b rspsibl fr h limi pak f FP vchrs i h

arg pplai. Markig shl b sig arss hs -

cmic barrirs b likig h vchr bra a prcpi f saf.

CAPItALIZAtIon: IMPACt on PRoVIdeRS

Ma prvirs, lik Hrma nrsig Hm i nairbi a nma

Hspial i Kii, hav s h aiial rv frm vchr

pais xpa hir faciliis, prchas bs, b qipm agrars, a hir aiial saff. Sm faciliis hav xpa h

rag f srvics h ffr b isallig a simpl srgical har

hal prcrs ha prvisl ha b rfrr (Mai al. 2008).

I aii spprig h css f car a chic amg pais,

h vchr prgram has allw prvirs capializ mch mr

rapil ha h cl hav wih h prvis lvl f ma.

ths h vchr prgram sbsi, b bfiig pais ircl,

als rprss a ivsm i h halh car ssm a larg.

Frhrmr, i is a arg ivsm, i ha prvirs hmslvs

ar makig cisis ab hw sp h aiial rv whri will b ms sfl.

I wl b irsig rsa hw h aiial rv

gra b h vchr sbsi has iflc ak-hm pa fr

prvirs. th VMA migh csir a mhl r qarrl srv f

prvirs mir h cmic impac f h prgram bh

ak-hm pa a h spcific capial ivsms h chs mak.


21/28


PRoGRAM CoStS

tabl 4 prss h prgram css fr h SM a FP vchrs fr

h pri Jl 2006ocbr 2008. th al prgram xpir,

iclig vrha css a rimbrsm prvirs, is giv iKa shilligs a i rs as rpr KfW a h f Phas I i

ocbr 2008. th pri f css sp maagm, raiig, a

markig is 21 prc f h prjc bg.

table 4: tOtal exPenDitures On Phase i OF the

Oba VOuCher PrOgram, June 2006OCtOber

2008

All amounts are as reported to KfW in 2008.

epd eo Ks

dirc srvic css

Rimbrsig GVR VSPs 8,908 914,184

Rimbrsig FP VSPs 201,810 19,817,182

Rimbrsig SM VSPs 4,621,540 463,195,705

Subtotal 4,832,258 483,927,071 79%

Maagm css

disribr raiig 8,109 804,410

Bak chargs / miscllas 10,277 1,034,950

GVR VSPs raiig 10,723 1,063,650

PwC pricig rpr i 2006 14,165 1,405,131

Prcss mirig (nCAPd) 18,554 1,840,541

Cmmissi isribrs 49,246 4,970,929

VSP accriai a raiig 63,785 6,223,222

Qali assrac (nHIF) 138,775 14,004,090

Markig a cmmicais 192,871 19,132,386

PwC maagm f 764,000 76,170,827

Subtotal 1,270,505 126,650,136 21%

tal xpir 6,102,763 610,577,207 100%


22/28


th Ka vchr prgram was implm arss h brf rprciv a priaal mrbiiis i h cx f a rapil

grwig pplai wih a saga s f mr FP mhs. A h

sam im, h prgram was sig ircl sbsiiz ilizai

f rprciv halh srvics amg h pr, a accsm

h nCAPd maagm am a halh car prvirs a

rimbrsm ml f pam.

upak f h SM vchr srpass args a acc fr arl

half f all livris a crac faciliis. Hwvr, FP vchr pak

rmais lw; wih a risig tFR, his vchr shl b a high priri

gig frwar. th 2003 KdHS f ha 44 prc f marri

wm wa mr chilr, a ha h ms cmm rass

fr sig a mr FP mh hav wih far f harmfl si

ffcs a prsal r rligis ppsii. Wll-sig markig

ca imprv h prcpi f FP saf a mphasiz h avaags

f a smallr famil. Fcs grps ma b bficial i frhr xplrig

barrirs pak amg Ka wm. Giv ha FP was icl

i h rigial vchr prgram (iicaig ha icras FP pak

was a gvrm priri) a rcgizig h rmarkabl lw css

amiisr h FP vchr (1 prc amiisraiv css), chags

cl b ma imprv pak. Lw pak a sggss ha

markig ffrs hav b fll ffciv. Alraiv markig

summary


23/28


sragis ma crag pak. oprais rsarch i FP pais

cisi-makig prcss cl als hlp iif pak barrirs b

markig csrais.

thr is a fr prvirs maiai saars f car a fr hprgram mir cmpliac. th x a qali f prgram

mirig is clar frm crr cmai, a i is likl ha

br mirig ffrs cl bfi h prgram. Srvic aa

ar cllc b PwC a shar wih nCAPd a KfW; hwvr,

aiial aa srvic qali a facili fiacs cl imprv h

mirig ffr.

I is impra ha hr b a rigrs amp sima h

pplai impac f h vchr prgram. t his, prgram fs

wl b s asi r xral rsrcs accss mak

cmpariss bw pplais srv a srv b vchrs.

Assssig pplai impac ma b pssibl lss h prgram

xpas a w srvic r a w ggraphic ara, wih a basli

hshl srv cllc aa pr-prgram halh cms i

aras wih a wih accss h vchr. Wih aa frm a fllw-

p srv afr 1218 mhs, cmpariss cl b ma avrag

halh sas f pplais xps h vchr srvic a

pplai xps.

th valai shl als csir h prgrams cs-ffcivss.

daa wl b raw frm cliics ha accp vchrs,b which ar hrwis similar cliics ha accp vchrs. Css

a pai cms cl b bsrv a cmpariss ma h

rlaiv cs-ffcivss f h vchr srvic. Mhl r qarrl

srvs f prvirs cl b s masr h ffc f h prgram

capial ivsms ma b prvirs, a cmpar rimbrsm

ams wih prvir css a fs fr -vchr pais.

th vchr prgram is bgiig a sc phas i which h crr

srvics will b xpa wihi h sam ggraphic aras. I his

xpa prgram, hr ar ppriis csir hw a larg

mbr f srvics, prhaps v a primar halh car packag, wl

pra ffcivl r a claims rimbrsm ml. up w,

h maagm agc has assm ha a f-fr-srvic ml is

h apprpria srag; hwvr, vic frm acrss h glb

iicas ha paig fs fr ach srvic is likl ic ilizai

b wha is cs ffciv c srvics amabl spplir

ic ma ar a h packag (Labll al. 1994).


24/28


Spplir-ic ma ma parl xplai h icras i C-scis

as highr rimbrsm ras fr h prcr ma b icig mr

C-scis ha cssar r sirabl. I h crr rimbrsm

schl, rmal livris ar rimbrs a $72 a cmplica

livris ar rimbrs a $292. thr is vic ha C-scisicras sigifical afr faciliis wr crac, which ma hav

b h mch highr rimbrsms allw. Irsigl,

a cmparis f h prpri f C-scis amg vchr a

-vchr clis i h firs w ars f h prgram shws

ha h prpri is highr amg h -vchr clis. o

alraiv pricig ml is a cas-bas apprach i which a avrag

pric wl b pai fr all livris. Sch a apprach cl rmv

prvir icivs ha crag cssar bsric srgris.

ur h xpa prgram wih is

aiial srvics a mr cmplicamaagm, i ma mrg ha a cas-

bas rimbrsm srag, wih fwr

pric pis a grar iciv fr cs

caim, is mr ffici.

I h xpasi, w faciliis will likl

b a, iclig lwr-lvl gvrm

halh pss ha charg fr

rmal livris, lik highr-lvl halh

faciliis a hspials. th mivai

icl sch halh pss is frhr

habia h gvrm halh ssm

a rimbrsm prcss as a pam

ml fr pblic halh car. Hwvr,

h fr srvics rprs a pak

challg vchr srvics ha charg

a c-pam f KSh 200. th maagm

agc ma hrfr rcsir

vchr pricig pais. Whil prprl

For every woman who dies in childbirth, up

to 20 women suffer morbidities, often with

severe medical and social consequences.


25/28


iciviz vchr isribrs ar h primar ga-kprs fr

vchr s, h pric f h vchr islf is a impra scar

mchaism fr argig a fra prvi. Ciig charg

fr h vchr ma rmi ilizai fr fr srvics, r riv

pais s rcivig rmal livr car fr f charg back ih has f rai birh aas. o h hr ha, isribig

h vchr fr f charg ma fail chck fra. Bh pial failrs

shl b csir wh sig h pric f h vchr.


26/28


ACKnoWLedGMentS

this cas s scribs h challgs a cisis ma i sig

p a rig h KfW-f Ka op-Bas Apprach (oBA)

vchr prgram. th ahrs ar grafl saff a KfW, h Kanaial Criaig Agc fr Pplai a dvlpm, a

Miisr f Halh fr hir sppr a giac. th ahrs hak

h Pplai Ccil fr sharig prjc cms a h imags f

phgraphr Richar Lr.

th als hak Ra eichlr f Bra Brach Asscias fr hr rviw

f h cas s, a h uSAId-f Halh Ssms 20/20 Prjc,

l b Ab Asscias, which f h papr.

drs. davi Griffih a Clas Jaisch pla k rls i mivaig

irs i h vchr ml amg Ka cllags a sharig hKa vchr ml wih iraial parrs.


27/28


ReFeRenCeSBllws, B., M. Hamil, a F. K. 2009. Vchrs fr Halh: Icrasig

ilizai f facili-bas FP a saf mhrh srvics i Ka.Bhsa, Md: Halh Ssms 20/20 prjc, Ab Asscias Ic.

Bllws, B., e. Mlg, a F. Baga. 2008. evalai f p-bas ai(oBA) i ugaa: Impac f crac faciliis a scial markvchrs kwlg, ilizai, a prvalc f sxall rasmiifcis (StIs) 2006-2007. Brkl, Califria: Vr Sragis frHalh a dvlpm.

Bllws, B., F. Baga, a e. Mlg. 2007. Prlimiar rpr: StI Prvalca Bhaviral Srv i Mbarara, Kirhra, Ibaa, Isigir a Bshidisrics - 2006. Brkl: Vr Sragis fr Halh a dvlpm.

Griffih, d. 2004. HIV/AIdS Prvi op-bas Ai: Ircig vchrssms fr halh car prvisi i ugaa (Prlimiar dsig). Frakfr:KfW (Grma dvlpm Bak).

Grsskrh, H., R. Gra, R. Has, d. Mab, a M. Wawr. 2000. Crlf sxall rasmi isass fr HIV-1 prvi: ursaig himplicais f h Mwaza a Rakai rials. Lac 355:1981-87.

Grsskrh, H., J. t, e. Mwijarbi, P. Maa, A. nicll, G. ka-Gia, J. nwll, H.Grsskrh, J. t, P. Maa, A. nicll, J. nwll, d. Mab, R. Has, F. Msha,K. Skr, J. Chagalcha, A. Klkk, e. Mwijarbi, G. ka-Gia, a K. Mg.1995. Impac f imprv ram f sxall rasmi isass HIV ifci i rral tazaia: ramis crll rial. th Lac346(8974):530-36.

Hagmr, e. 2005. Fial rpr prgram sig fr oBA i ugaa. Brli:IGeS.

H, M., e. ows, a P. M. Aki. 2009. ClaimMbil: egagig cflicig

sakhlr rqirms i halhcar i ugaa. Prs aIraial Cfrc Ifrmai a Cmmicai tchlgisa dvlpm, April 17-19, Cargi Mll uivrsi i Qaar; iICtd2009.

Kiwaka-Mkiibi, P. 2005. Ircig vchr ssms fr halhcar prvisi:Basli ai. Kampala: PS Cslig.

Kmh, G. B. 2003. Lw us f Rral Mari Srvics i ugaa:Impac f Wms Sas, traiial Blifs a Limi Rsrcs.Rprciv Halh Mars 11(21):16-26.

Maa, P. a d. Mab. 2004. Apprachs h crl f sxallrasmi ifcis i vlpig cris: l prblms a mr

challgs. Sx trasm Ifc 80(3):174-82.nwaha, F., e. Faxli, S. nma, a B. Hjr. 1999. La ppls prcpis f

sxall rasmi ifcis i ugaa. I J Std AIdS 10(11):709-17.


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Health Systems 20/20 is a ve-year (2006-201cooperative agreement No. HS-A-00-06-00010-funded by the U.S. Agency for InternationalDevelopment (USAID). The project addresses nancing, governance, operational, and capacitybuilding constraints that block access to and uspriority population, health, and nutrition servicby people in developing countries.Health Systems 20/20 offers global leadership,technical assistance, training, grants, research, ainformation dissemination.

Abt Associates Inc. (www.abtassociates.com) lea team of partners that includes:| Aga Khan Foundation | Bitrn y Asociados | brUniversity | Broad Branch Associates | diConsulting, LLP | Forum One CommunicationsInternational |Training Resources Group |TulanUniversity School of Public Health

DISCLAIMER: The authors views expressed her

do not necessarily reect the views of the U.S.Agency for International Development or the UGovernment.

For more information about Health Systems 20/please contact:h s 20/20 | www.healthsystems2020Abt Associates Inc. | www.abtassociates.com4550 Montgomery Lane| Suite 800 North | Bethesda, MD 20814 | usaE-mail: [email protected]| www.healthsystems2020.org

rcodd Co: Bellows, Ben, MattHamilton, and Francis Kundu. September 2009.Vouchers for Health: Increasing Utilization of FaciliBased STI and Safe Motherhood Services in UgandMaternal and Child Health P4P Case Study.Bethesda, Maryland: Health Systems 20/20 projAbt Associates Inc.

Photos: Ben Bellows

vouchers for health: increasing utilization of facility-based family planning and safe motherhood...

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