vouchers for health: increasing utilization of facility-based sti and safe motherhood services in...

8/8/2019 Vouchers for health: Increasing utilization of facility-based STI and safe motherhood services in Uganda

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P4PC

aseStudies

Vouchers for health:IncreasIng utIlIzatIonof facIlIty-Based stIand safe Motherhood

serVIces In ugandaB Bllws a Mahw Hamil

Inside

Ab h P4P Cas

Sis Sris 2

Acrms 2

Irci3

Backgr5Prgram Srcr

a Maagm10

Masrig

Prfrmac20

Cclsi26

Rfrcs 28

This case study shares the experience of Uganda using vouchersto stimulate uptake of services for sexually transmitted infections

(STIs) and safe deliveries. P4P was rst introduced to increase

treatment of sexually transmitted infections (STIs); later a safe

motherhood component was added to augment the number of

facility-based deliveries. Specic vulnerable groups are targeted andreceive subsidized vouchers, which they can use to access services at

accredited private clinics. Findings reveal that STI symptom knowledge

increased and that the reduction in syphilis prevalence was greater

among respondents who lived closer to contracted private facilities.

Yet STI treatment utilization did not increase signicantly and the

program experienced a handful of challenges (for example, with

claims management). This case study provides an example of how

a Government can regulate the private health sector through use of

nancial incentives and offers lessons for countries wishing to expand

service access to safe motherhood and STI treatment through P4P

engagement of private sector providers.


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Case Studies - Uganda

IntroductIon

This cas s scribs vchr srvics vlp fr ramf sxall rasmi ifcis (StIs) a saf mhrh (SM)

priaal car i ugaa. t arss vr pr rprciv halh

cms a iffici halh car maagm, h ugaa Miisr

f Halh (MoH), wih sppr frm h Grma dvlpm Bak

(KfW), carri a fasibili

s i 2004 a, i 2005,sig a ivaiv vchr

prgram fr StI ram ha

rsrcr icivs pais

a prvirs. A similar prcss

was rak fr h saf

mhrh vchr i 2007

a 2008. th pil srvics wr

lach i wsr ugaa i

rsps h pblic halh

: prvalc f ma StIswr a pimic lvls a

mr ha 55 prc f wm

wr livrig a hm, whr

h wr a highr risk f lif-

hraig cmplicais, rahr

ha a a halh facili.Local clinics such as the FP Association of Uganda allow patients to

redeem their vouchers for SM and STI services.


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4 P4P Case Studies - Uganda

Bgiig i 2006, vchrs fr StI ram wr xsivl

mark vr h rai i h fr pil isrics f Mbarara, Isigir,

Ibaa a Kirhra. Paricipaig prvirs a mr ha

19,000 pai visis i h firs 22 mhs f h prgram. Mr ha

30 prc f vchr pais wr parr rfrrals a mr ha40 prc f pais wr m, wh ar vrall mch mr likl

sk ram a ifrmal rg shps rahr ha a a qalifi mical

prfssial. A impac valai f h pil f ha kwlg

f StI smpms, a impra facr i skig ram, icras

sigifical i h fr isrics a ha prvalc f sphilis fll

bw J 2006 a ocbr 2007.

th StI pil shw ha h vchr ml, which ircl liks

halhcar livr prvir rimbrsm, cl b ffciv a

icrasig ilizai f facili-bas srvics. Waig xpa h

ml, h MoH agr implm a saf mhrh vchr

prgram. dsirig ci h ml, h MoH agr

implm a vchr. th Wrl Bak agr shar fig wih h

Grma dvlpm Bak KfW h w srvic i 2007, a h

SM vchr was lach i 2008 wih h gal f paig fr 51,000

livris i h firs hr ars. th sam parrship agr

ci h StI ram vchr wih a w gal f raig 35,000

StI pais i h sam hr-ar pri.

this lar vchr prgram has w primar bjcivs: 1) rc

h isas br asscia wih maral livr a StIs, a2) mak halh car livr mr accabl b likig srvics

rimbrsm. Bcas h prgram ss priva prvirs, h

vchr ml als has giv h MoH grar lvrag rgla

priva scr halh car prvisi hrgh h s f fiacial

icivs. this pblic-priva parrship ca srv as a ml fr hr

gvrms csirig sragis wrk mr clsl wih h

priva scr.


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Background

StIS And PeRInAtAL HeALtH In uGAndA

StIS

StIs csi a larg halh a cmic br i ugaa a hrvlpig cris: 7585 prc f h sima 340 milli aal

w cass f h fr ms cmm crabl StIs (grrha, sphilis,

richmiasis, a chlamia) ccr i lw-icm cris, a StIs,xclig HIV, acc fr 17 prc f cmic lsss illss

i 1544-ar-l wm (Maa a Mab 2004). StIs als facilia

h sxal rasmissi f HIV, hrb iircl impsig aiial

mrbii, mrali, a cmic brs vlpig cris

(Grsskrh al. 2000; Grsskrh al. 1995).

I spi f h iscmfr a lg-rm sqla frm ma StIs a

h risk f ifcig hrs, ma iivials i ugaa wih a prbabl

ifci sk car. A 2006 pplai srv i wsr isrics

ar Mbarara w f ha h -HIV StI br was high; 7

prc f al rsps ha sphilis (pr h VdRL s fr sphilis)

a 5 prc f al rsps ha grrha (Bllws al. 2007).

y, ilizai f StI ram srvics was lw; h sam 2006 srv

f ha l a hir f rsps wh rpr havig a StI

smpms i h prvis six mhs sgh car.

ugaas fail sk ram fr StIs bcas f fiacial barrirs,

lack f kwlg, a ccr ab h qali f car. Lack f


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fiacial rsrcs is a majr csrai. Fiacial barrirs icl h

irc css f rasprai, cslai fs, a micai a

h iirc css f ls wrk. I h afrmi 2006 pplai

srv, lack f m was h ms cmm ras giv b

rsps wih StI smpms fr skig car (Bllws al.2007). I fcs grp iscssis cc b Sama Asscias

i 2005, rsps am h cs f ram a h lack f

raspr as cmm rass wh StI cass sk ram

(Hagmr 2005).

Lack f ifrmai StI smpms a whr sk car is ahr

cmm barrir skig StI ram. A 1999 s i h Mbara

rgi a gral misrsaig f StIs; s paricipas

am brclsis, lprs, a ski fgal ifcis as big sxall

rasmi (nwaha al. 1999). th 2006 pplai srv f h

vchr pil rgi iifi a mra lvl f kwlg f StI

smpms wih fwr ha 50 prc f rsps abl crrcl

am a las w smpms cmml asscia wih StIs (Bllws

al. 2007). Acall, i a ar Mbarara, sphilis is a rm s fr a

wi rag f halh cmplais frm rashs backach.

Fiall, ma ugaas hav a lw pii f h qali f car a

cliics (Kmh 2003). Ma pais i visi pblic halh

car prvirs, blivig ha h faciliis wl ihr lack rgs r

hav xpir rgs. Prvirs rspc pais a ar kw

vrball abs mhrs wh brig aaal cars, r maiscls a pais StI sas i gssip (Hagmr 2005; Kmh

2003).

MAteRnAL HeALtH

th 2006 ugaa dmgraphic a Halh Srv (udHS) rpr

bsrv f h wrls highs sima al frili ras, wih

a avrag f 6.7 chilr br i a wmas lifim (ugaa Bra f

Saisics a Macr Iraial Ic. 2007). th sam rpr sima

ha l 43 prc f maral livris k plac i a halhfacili. I als bsrv appar scicmic iqaliis i facili-

bas birhs. Rral wm wr mch lss likl livr i a facili

ha rba wm: l 40 prc f rral livris ccrr i a

cliic, cmpar wih 80 prc f rba livris. ol 27 prc

f wm wih cai livr a faciliis, cmpar wih 42

prc amg wm wih a primar cai a 75 prc amg

wm wih a scar cai (udHS 2006).


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Wm livrig si a halh facili ar a high risk f maral

mrbiiis a ah as h lack accss lif-savig rams lik

bsric srgr, bl baks, a vasclar csriciv micais

sch as misprsl. I is sima ha 400-500 ugaa wm i

i chilbirh pr 100,000 liv birhs (udHS 2006). I cras, maralmrali i ma high-icm cris is lss ha 15 ahs pr

100,000 liv birhs.

y givig birh a a halh facili ails sigifica css pais

familis. ev a a pblic facili, alhgh pais ar picall

charg fr h prvirs im, h ms prchas h cssar

micais a prvi basic mical spplis. Fr livris, spplis

wl icl glvs, gaz, blaks r shs, a plasic bags fr

ispsal f was. Priva faciliis charg cslai fs i aii

all h abv css.

oRIGIn oF VouCHeR SeRVICeS In uGAndA

KfW pla a impra rl i ccpalizig a fiacig h StI

pil vchr prgram. Fr 10 ars prir h vchr prgram, KfW

ha fiac h scial markig f cms hrgh h prfi

Mari Sps Iraial (MSI). I dcmbr 2003, wih h agrm

f h MoH, KfW rw is eas Africa

HIV prvi prfli icl: 1) a hir

fiv-ar phas f a cm scial markig

prgram a 2) cllabrai wih h priva

scr hrgh a vchr ssm wih a fcs

StIs. th sa gal f h KfW prjc was

rc HIV rasmissi b vlpig ffciv

a ffici allcai f all halh srvics

iclig hs ffr b h priva scr;

icrasig prviv kwlg, ai a

bhavir amg h arg pplai; rcig

HIV/AIdS rla sigma a iscrimiai, a

imprvig accss high qali a affrabl

pric cms (Griffih 2004). KfW was

irs i h vchr prgram as a masr

ha, i aii frhrig pblic halh gals,

wl b a prmisig halh fiac srag

ha cl vrcm mlipl barrirs

ffciv halh car livr.

A nurse instructs patients on how

to properly complete a claims

reimbursement form.


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Fr is par, h MoH csir h StI vchr prgram a prmisig

srag livr sbsiis arg grps, hs rmvig fiacial

a hr barrirs accssig StI ram. I als saw h prgram

as a vhicl fr icivizig br maagm i h priva scr

halh car h miisr fl ha h prgram cl b s saariz h highl variabl qali f priva scr halh car. I

a cas, i wl hav b ifficl crac pblic cliics

cs-sharig csrais rimbrsms wl hav g h

isric halh bg rahr ha ircl h facili, prviig lil

r mchaism b which hl pblic prvirs accabl fr

srvic qali.

Prcrm f fiacig, vlpm f h scp f prgram

aciviis, sig vchr isribi gals, a plaig h prgram

rll- k w ars. I 2004 a 2005, hr wr plaig migs

bw h MoH, KfW, ugaa sakhlrs i h prfi a

halh scrs, a erpa cslas wih xpric i vchr

prgrams. B J 2005, h vchr ccp was fram. th MoH

iifi h grar Mbarara rgi as a ara wih ma priva

prvirs availabl crac. I was als wihi fr hrs f Kampala,

allwig fr asir mirig a maagm fllw-p. MSI was

awar h rl f vchr maagm agc (VMA) giv is

prvis wrk wih KFW i cm scial markig a srg

isiial hisr rig a wrk f rprciv halh cliics.

A high-lvl wrkshp was hl i Frakfr, Grma i J 2005

rais awarss f h prgram amg iraial parrs a

irs paris (u.K. dparm fr Iraial dvlpm,

dKt Iraial, Ab Asscias, uSAId, a MSI, amg hrs). o

ar lar, MSI rgaiz h fficial prgram lach a h Mbarara

Lakviw Rsr.

Alhgh MSI ha vchr maagm xpric prir J

2006, h rgaizai i hav sigifica xpric i scial markig

f cms. tha backgr was impra cvicigl isrib

StI ram vchrs h gral al pplai f h Mbarara

rgi. MSIs capaci maag claims rimbrsm, markig, fracrl, a hr ssms i vchr srvics grw wih h prgram.

th SM vchr srvic was ccpaliz i J 2006 as a wa

icras h prpri f pr wm livrig a a halh facili.

th SM srvic, bil p f MSIs vchr maagm xpric

gai i h StI vchr rll-, cvrs h css f hr aaal

car (AnC) visis, facili-bas livr iclig a mrgc

bsric car, a psaal car (PnC) visi. Icl i h


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AnC packag is malaria prphlaxis, ir spplms fr amia, HIV

scrig a srvics, a gral mirig f h halh f mhr

a fs. PnC mirs h halh f h wbrs a h mhrs

rcvr. th vchr prgram rimbrss faciliis fr mical

spplis, xamiais, rgs, a pas a cslai f fr rmal acmplica livris.

th iiial prpsal call fr 100,000 vchr livris i hr

ars fr 22 isrics f wsr ugaa, cvrig a al pplai

f apprximal 8 milli. I 2007, h Glbal Parrship op-

bas Ai (GP-oBA) a h Wrl Bak sig h gra fiac h

SM vchr srvics. th prgram was fficiall lach i ocbr

2008, a h firs vchr bab was br Fbrar 28, 2009.

Lik h StI vchr prgram, h SM prgram cracs wih priva

prvirs. Pblic faciliis ar icl bcas h crrl

hav h capaci rciv rimbrsms ircl, which is hgh

cssar sppr prvir accabili. th crac priva

faciliis ar grp bral i w cagris. th firs ir ss

pais fr AnC, livrs rmal birhs, rcivs mhrs a babis

fr PnC, a ccs ri StI iagsics a ram. A sc

ir f largr faciliis ar rfrral sis fr cmplica livris a

StI cass. Fw faciliis prvi bh StI a SM srvics; ms prvi

l StI r l SM car.

I shl b ha havig champis i h MoH cribgral h sablishm f h vchr prgrams. dr. elizabh

Maraa f h MoH Std/AIdS Crl Prgramm was a k

spprr f h StI vchr pil. Hr safas ivlvm was

impra i mvig h prjc hrgh h miisr a sig i

lach i J 2006. dr. Maraa wrk clsl wih h ircr f

MSI-ugaa, Chrisi namaaja, vlp a fcial prgram i

which h MoH wl hlp imprv bh pai chic a priva

scr halh car qali hrgh h prchas f halh car i h

priva mark.

th SM prgram was champi b dr. Ah Mb, MoH

assisa cmmissir fr rprciv halh. dr. Mb wrk

clsl wih MSI sig a prgram ha wl m h MoH plic

bjcivs f rc maral mrali a mrbii.


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StI PRoGRAM Set-uP And MAnAGeMent

Bfr h StI vchr srvic was lach i J 2006, MSI pa vchr maagm ffic i Mbarara w cria claims

prcssig, cliic sprvisi,

vchr isribi, a gig

markig ffrs. MSI ha

ci hw accri cliics,

vlp ifrmai ssms, rack

fiacial flws, a crl fra.

Figr 1 pics h StI prgram

srcr a fcis fr ach

f h majr acrs. Prgram

srcr fr h SM vchr

srvic is iical, alhgh h

w prgrams pls f prvirs,

pais, a isribrs ar

isic.

PrograM structureand ManageMent

A patient verifies the accuracy of a claims

reimbursement form by providing a thumbprint.


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Figure 1: OrganizatiOnal FlOwchart FOr

the uganda Sti VOucher PrOgram

StI VouCHeR PRoGRAM BudGet

tabl 1 smmarizs MSI prgram xpss fr h gig StI vchr

prgram frm Ma 2006 Ma 2008.1 th css f pai car i h

frm f pams rmi prvirs fr h css f ram

(Claims Rimbrsm) rprs a rlaivl lw 18 prc

f css fr h w ars shw. th vrha im Claims

Prcssig rfrs claims aa r a aabas maagm a

acc fr rlaivl high 21 prc f css. A mial icm

(Vchr Icm) cam frm vchrs sals.

1 Atu t t uc t ccuat ut Juy 2006, t pam

cu ay makt ct a t-up xp tat tabuat fm May

2006 a. A t tat t pat f t pt, t uc cam ata y

ctu t Ap 2008, a t accut u Tab 1 ctu t May 2008.


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table 1: Sti VOucher PilOt PrOgram cOStS

recOrded by mSi, may 2006may 2008

Apprximal 15,000 pais (20,000 pai visis) wr s rig

his pri wih mlipl visis fr ab -hir f h pai

pplai. Bas h fll prgram bg, h mbrs f pais

s rprss a avrag cs f $53 pr pai. th prgram qali

cl b maiai a fficic imprv wih rcis i prgram

vrha css, pariclarl i h ara f claims prcssig.

th StI vchr rimbrs h cs f lab ss, ram, a a

cslai f sparal, rahr ha sablish a sigl cas-bas

rimbrsm pric fr all StI pais. o ccr was ha bcas

prvirs ar rimbrs fr ach srvic i h pai visi, h ar

iciviz src h chaps ips a mak a prfi h

iffrc bw wha h pai fr h ips a wha h wr

rimbrs b MSI.

FACILIty SeLeCtIon: StI VouCHeR SeRVICe

A Kampala-bas cslig firm w b dr. Pal Kiwaka, PS

Cslig, was crac iif apprpria cliics fr h StI

prgram i J 2005. Prvirs wr firs iifi frm facili liss

kp b h rgisrig bis, h ugaa Mical a diss Ccil

a h Alli Halh Prfssials Ccil. Frm availabl rcrs, 79

eXPenditureS2006 2007 2008

tom - d J - d J - m

Gral praig css $85,608 $107,008 $37,717 $230,334

BCC markig css $23,950 $48,522 $6,621 $79,093

Rai a tV markig $235 $12,614 $3,074 $15,923

evalai a prgram sar-p $18,407 $12,658 $8,754 $39,819

Claims prcssig $69,365 $80,245 $16,268 $165,877

Cslac css $34,455 $23,196 $33,924 $91,576

traiig a rcrim $42,951 $1,420 $970 $45,341

Claims rimbrsm $19,494 $93,514 $25,264 $138,272

totAL $294,466 $379,177 $132,592 $806,235

Vchr icm $5,559 $10,077 $2,235 $17,871

n xpir $288,906 $369,099 $130,358 $788,363

% fr pai car 7% 25% 19% 18%

n: All css wr calcla sig a xchag ra f uSh 1,700 pr uS$1.00, pical fr his pri


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priva faciliis wr iifi i Kirhra, Ibaa, Isigir, a Mbarara

isrics. tw-igh faciliis wr srv wih a saariz

isrm (Kiwaka-Mkiibi 2005).

MSI a h MoH agr a lis f sirabl ifrasrcr aqipm characrisics: a basic lvl f labrar capaci (fcial

micrscp a gram saiig), prsc f lcrici rig sm par

f h a, lph r rai call, rig war, r mr priva

ram rms, arb rg sr r pharmac, ils, was ispsal

(icirar r hr), s f Jik r hr srilizai, prsc f a lab

chicia r assisa, a s f ispsabl prcs. Alhgh l

half f h faciliis ha rig war, all ha ha-washig faciliis, wih

war carri h prmiss i jgs. Cliics i Kaz traig Cr

ha vr limi labrar capaci, fr isac, b h cliics wr

crac spi his bcas h ara was csir rsrv.

All faciliis ha h capaci carr a cmbiai f srmic

a lab-bas StI iagsis. All b fiv cliics ha labrar srvics

fr StI iagsis a ram h prmiss. tw f h fiv cliics

ha a rlaiship wih a arb labrar. of h 23 faciliis ffrig

labrar srvics fr StIs, ms cl cc VdRL/RPR as wll as

bh gram saiig a simpl ivsigais rqirig micrscp.

Ms cliics alra ha a rfrral ssm i plac fr cmplica StI

cass, sall rlig h ars i pai (f pblic) facili.

HeALtH And FInAnCIAL MAnAGeMent

InFoRMAtIon SySteMS

I vr vchr prgram, chical a fiacial ifrmai

maagm is criical fr fra crl, mirig pai halh, a

imprvig faciliis chical a fiacial cmpc. I dcmbr

2005, MSI crac Micrcar Limi, a priva israc cmpa

i Kampala, vlp a aabas maag h chical a fiacial

ifrmai cai i pai claims frms; his wl icl

iifig fral a imprprl cmpl claims. th iiial

ccp prvi a gral srcr ha cl hav bfi a

ims frm aiial praial ail (H al. 2009). I fr

isac ha a h f ach mh, h [h prvirs] ha i

rspcivl h claims prcssig agc [Micrcar] cllcs (pag

7). Lf arss wr ails sch as: Was h prgram criar

spps riv ach facili cllc claims? Wr prvirs

xpc carr claims h Mbarara vchr maagm ffic a


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hir w xps? Hw wl icivs b s crag claims

b sbmi ach mh? Aiial ails cl hav hlp h

iiial ssm prfrm aqal. Alhgh a irim sli was

i plac b 2007, h parrship bw Micrcar a MSI cam

a ar h clsr f h firs pil i 2008. MSI ci rviw StI claims a archiv aa sig cmml availabl sprash

sfwar fr h rmair f 2008.

I Fbrar 2009, MSI crac Ls L., a Kampala chlg firm,

vlp a w aabas a ifrmai ssm fr bh h StI a

SM vchr srvics. th w ssm will icrpra h lsss f

h iiial StI prgram. MSI ci s sprashs maag

mical a fiacial ifrmai i bh h StI a SM prgrams il

h lach f h w aabas i Jaar 2010.

VouCHeR MARKetInG And dIStRIButIon

StI VouCHeRS

As abv, h arg pplai lack kwlg f StI

smpms a whr sk ffciv car. t rach larg mbrs, h

StI vchr prgram cl rl wr-f-mh pblici; i ha

r a ssiiv b xsiv campaig. Fr xampl, h lagag i

prmial marials ha b ssiiv i rr capr aic

ai a ca hm ab StI smpms a ram.

t bil is campaig, MSI rw is ma ars f xpric wih h

scial markig f cms. I arl 2006, i vlp a mlimia

srag ifrm h arg aic a prm h vchrs:

h StI vchr was bra HalhLif, wih a clrfl lg ha

appar bh h vchr a h placars ha iifi

paricipaig faciliis a isribi lcais (msl small rg

shps). Prir prgram lach i mi J, rai avrisms wr

r fiv rgial sais. Rai call-i shws a call-i qizzs als

wr bracas, sig ca lisrs StI smpms a

icras awarss f h HalhLif vchr. MSI saff maag mark

a bhs ha ha prgram ifrmai. MSI brrw a MoH

film vhicl shw caial films ab StIs a h vchr i

slc villags. Figr 2 iicas h mbr f hrs f markig

cc ach mh b MSI.


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Figure 2: number OF radiO hOurS

(adVertiSementS and talk ShOwS) Per mOnth

OVer the FirSt 16 mOnthS OF the Sti VOucher

PrOgram

oc ma was cra, MSI ha b sr ha h ssms wr

i plac isrib vchrs h pplai. MSI sl vchrs a

small rg shps fr uSh 3,000 (apprximal $1.80) a iivial

wh cmplai f StI smpms. th vchr pric rprs a

sima 80 prc savigs vr avrag -f-pck xpss f

uSh 15,000 fr StI ram i h rgi (Bllws al. 2008). th

vchr i cvr raspr css, which ca b prhibiiv fr h

prs StI pais. I h firs w ars f h prgram, mr ha 80

shps paricipa a im r ahr; a a giv im, hr wr

ab 40 shps sllig vchrs.

ulik ma hr vchr prgrams, h ugaa StI srvic i

s a xplici pvr graig mchaism rmi vchr

ligibili giv h rcgiz fr a prvir s all prss

wih a pial StI, a wh hgh h/sh migh hav a StI

was crag prchas a vchr a sk ram. I was

als assm ha i a sci wih s vrlappig sxal wrks

a high HIV risk, hr wr sigifica prviv halh bfis

sig as ma ppl as pssibl. Pais s half f h vchr aaccri faciliis a wr crag giv h hr half f h

vchr hir sxal parr.


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sM Vouchers

I was assm ha SM vchrs wl b asir mark ha StI

vchrs as h wl bfi frm wr-f-mh prmi s lg

as h srvic was grall s as high qali. Fr xampl, mhrs

rrig hm wih hir wbr wl b ask immial ab

h lvl f vchr-f car i a wa ha StI vchr srs wl

. nvrhlss, i 2009, MSI vlp a rai campaig rais

awarss f h SM vchrs.

MSI cracs cmmi-bas isribrs (CBds) sll h SM

vchr qalifi lw-icm mhrs. CBds frql liv i h

sam villag as h xpca mhrs, r a ighbrig villag. th s

a pvr graig l scr h mhr rmi hr ligibili

fr h vchr. If h wma scrs lw gh h pvr

graig l, sh is ligibl prchas h vchr fr uSh 3,000(apprximal uS$1.60).

th pvr graig l ss privai iicars ha MSI vlp

i 2007 bas paricipar xrciss hl wih cmmi fcs

grps; h xrciss gla h grps fiiis a prcpis

f pvr (Prks 2003). th iicars var b isric. Fr isac,

cmmi grps i h Kjj isric csir a wma pr

if hr famil a msl cassava r pas wih sac wih l

r w mals a a, if hr was a r sgar i h hm, if h

hs was bil frm sri m r grass, a if h hshl ha

fch war frm h rivr wih a filr, ha a small pl shar

wih hr familis, ha fw livsck b la fr grazig, ha

lari, a visi raiial hrbaliss. I Mbarara isric, wm

wr rmi b pr if h a l ail mal f sam,

mash baaas (mak) r gr maiz prrig (psh) wih

sac, if hir hms wr ma f sri bricks, a if h rw

war frm a prc wll, ha fwr ha hr aimals, i

w la, ha shar a lari, a cl affr visi priva

cliics a gvrm faciliis accss b raspr.


17/28

17P4P


A nurse tries a pilot mobile information

technology application as part of ongoing

management innovation in the OBA project.

claIMs ProcessIng

Vial h sccss f a vchr prgram is a ffici ssm

f claims rviw a aa r allwig fr rapi claims prcssig

a prvir rimbrsm. this fr bh accrac a spcras a irsig si i h claims rviw prcss: accra

claims rviw, which icls rviw fr mical a fiacial accrac,

iifis r fra wh i happs. Sp claims rviw is

rai prvirs i h prgram. I bh vchr srvics, i ca ak

mr ha w mhs frm h im h pai is s h a h

lcric pam h prvir is apprv.

claIMs forM detaIls for stIs and sM

I h ugaa vchr prgram, ach prvir has fil a claim afr

sig a vchr pai (Ax A has cpis f h claims frms). th

StI claims frm is a sigl pag cmig vchr mbr, pai

rsic a mgraphic aa, rlva halh hisr, prsai

wih a srm, h rsls frm a lab r cliical ivsigai,

h iagsis, a ram ails iclig all

srvic rla css. th pai givs his r hr

hmbpri, h mical fficr a pharmacis

(if ivlv) als sigs. th SM srvic cvrs

AnC, livr, a PnC css. Spara frms

ar s fr ach p f car. th AnC claim

frm is w pags a rcrs vchr mbr,

pai rsic, crr prgac saisics,

rlva halh hisr, rsls frm phsical

xams, a micais giv fr prgac-

rla ciis, a imiz srvic-rla

css. th livr frm is w pags a

rcrs h vchr mbr, pai rsic

a mgraphics, livr prsai, h

wbrs ails iclig APGAR scr,

mhrs ps-livr prsai, a

micais giv, a h imiz css frcliical im, rgs, a hr srvic-rla

css. th PnC frm is a sigl pag a

rcrs vchr mbr, pai rsic a

mgraphics, ps parm hisr, phsical xamiai, cslig

srvics prvi, rgs, a imiz srvic css. each claim ms b

accmpai b h rigial vchr sb, which is agg wih a iq

mbr ahica h vchr.


18/28


claIMs reVIew for stI and sM serVIces

th prvir ihr priicall carris claims frm his r hr facili

Mbarara r has h claims livr i bachs h vchr prjc

ffic i Mbarara. th rigial claims aabas sig b Micrcar

cl amaicall chck claims fr cmpliac wih mical a

fiacial saars; hwvr, i lack a mchaism ajs claims ha

wr flagg as cmplia. I h firs mhs afr h 2006 lach,

s ma claims wr flagg as cmplia ha a backlg f pai

claims accmla. I rsps his backlg, claims r saff bga

rack acal rimbrsm ams sig sprashs i aii

h claims aabas, rslig i ar plica claims r. I arl

2007, a phsicia was hir maall v papr claims. Hwvr, hr

wr wks wh h rviwr was availabl a h prvirs

cmplai ha h rviw rls wr icsisl appli. B

Fbrar 2008, fac wih prgram bg csrais, MSI ssp

h mical rviw prcss. I ocbr 2008, a w phsicia csla

frm Mbarara uivrsi was hir a bga a w r f carfl

mical rviw f h StI vchrs a, c h SM srvic was aciv,

rviwig h SM claims as wll. B Spmbr 2009, a am f fr

claims rviwrs a w mical avisrs rviw claims a m wih

prvirs wh ha prblmaic claims.

I aii mical rviw, ach claims imiz css hav b

rviw sic h prgram bga i 2006. If h claims prcssr fis

icrrc sms, h claims prcssr ajss h rimbrs amaccrigl. I sm cass, sspicis, illgibl, r icmpl claims ar

rjc. th claims rviw a aa r sall aks 23 wks. evr

wk a pam smmar sh is s MSIs Kampala ffic, which

h ss lcric fs rasfrs wic a mh prvirs bak

accs.

challenges wIth claIMs forMs

thr ar challgs i h crr claims ssm. thr ar blcks

i claims sbmissi a hr ar waksss i h claims isribi

a rimbrsm prcss whr fra cl happ. I spi f hs

challgs, h prgrams s f claims cs ach pai visi has

isic appal as srvic aa ms b rcr rciv pam,

prvirs ar iciviz maag srvic ips carfll pimiz

rv, a h prgram pas prvirs fr wrk ha is cmpl

rahr ha allcaig fs sima fr facili ilizai.


19/28

19P4P


thr ar hr rcgiz pis i h claims sbmissi prcss

whr las ca ccr: 1) h la i h halh cliic bw h

a h halh cliic ss h pai a h a h claim is sbmi,

2) h im i aks prcss h claims, rig ach i

h aabas, a 3) amiisrai f fback h halh cliics,spciall i cas f rrrs (H al. 2009).

Sic h bgiig f h ugaa vchr prgram, StI a SM

srvic prvirs hav b rimbrs accrig a gia

pric schl fr spcific srvics afr ach pai visi. Alhgh f

rimbrsm is appalig bcas i cvrs h iq cmbiai

f srvic css fr ach pai, hr ar siais whr iffr

ram rgims fr h sam isas hav iffr cs srcrs;

fr xampl, raig a pai wih sphilis cl b uSh 10,000 if

h pai wr prga a ra wih rhrmci a uSh

5,000 fr hr sphilis cass ra wih picilli. disigishig

whhr a fmal pai wr rl prga frm h claims frm

is impssibl wih aiial css vrif hr sas. th ms

wrrig pial fr fra r h crr ssm is a prvir

big vchrs frm isribrs a filig fak claims. thr is

crrl ri pai fllw-p: hwvr, blaa prvir fra

has b c a al wih i h pas. Fr isac, prvirs

hav sbmi a bach f claims i which 50 frms ar fr pais s

fr h sam sal cii i h sam wk a h hmbpris

lk sspicisl similar. I siais lik his, h MSI Mbarara ffic

maagr calls r visis h prvir iscss h sal claims. I

ma cass, h claims ar rjc r pai a fraci f h claim

am. I xrm siais, cliics ar ssp

frm h prgram.

I spi f irrglariis, fw cliics hav lf

h prgram. Zzimb a Kaz Cral cliics

vlaril lf i 2006 ciig rimbrsm

las a a lw vlm f vchr pais. th

prgram has ma a ffr wrk wih cliics,

mphasizig h prgram saars a makigprmp pams vr mh fr ach v

claim.

Health facilities participation in voucher programs

is based upon meeting specific criteria which assess

infrastructure and equipment characteristics.


20/28


As abv, h primar gal f h StI a SM vchr prgramswas icras car skig fr StIs a livr srvics (AnC,

livr car, a PnC). Sic h SM vchr prgram is sill i is

firs ar, i has b vala, alhgh a pplai impac

valai a halh facili assssms will b rak b Vr

Sragis fr Halh a dvlpm a h Pplai Ccil.

th fllwig scis fcs fiigs frm h arlir StI prgrampariclarl hw h gal f icrasig StI kwlg a s f StI

ram srvics was achiv.

QuALIty oF CARe

StI claims aa cai pai mgraphic ifrmai, villag f

rsic, ram a, labrar s rsls, iagsis, a a

rgs prscrib. th StI vchr srvic saw 19,656 vchr pai

visis bw Jl 2006 a April 2008. Svral iicars f prgram

prfrmac a srvic qali ca b gahr frm h rilcllc claims aa. ths iicars ca b s as par f ri

maagm cmpar qali amg prvirs a vr im, a

iif prvirs wh ma clsr sprvisi a/r aiial

raiig cmpl wih h saar f car. Prps StI iicars f

srvic qali a prgram prfrmac:

z Fraci f iagss crrcl arss wih ram, b isas

a b prvir.

MeasurIng PerforMance


21/28

21P4P


z Fraci f iagss bas a isas-psiiv labrar s, b

isas a b prvir.

z Apprxima cs pr cr vr h ir prgram, b isas

a b prvir. Calcla r assmpis ab accrac fiagsis a pai ahrc, as bs-, mil-, a wrs-cas

crss prc ssiivi aalsis.

z Variai i h qali f labrar ss, i rms f frqc f

icrrcl spcifi a prl rpr s rsls.

Figr 3 shws a hisgram f all iagss ma amg 19,656 pai

visis bw Jl 2006 a April 2008. elv f h ms cmm a

impra lab-bas iagss ar lis b am. A hafl f iagss

mia i h pai pplai; sphilis was ms cmm

(36 prc), fllw b grrha (20 prc), a caiiasis(12 prc), a spcific as ifci. Prvirs ccasiall

rpr ciis ha wr StI rla, sch as nrmal a

Prga.

Figure 3: a hiStOgram OF all diagnOSeS

rePOrted in the 19,656 Patient ViSitS July 2006

may 2008


22/28


A handful of diagnoses dominate; syphilis was most common (36%), followed by

gonorrhea (20%), and candidiasis (12%), a non-specific yeast infection.

Rlig hs claims aa ircl rprs h lvl f halh car

qali is challgig fr w rass: 1) pai fllw-p vrif whhrh StI was clar was xpsiv implm, a 2) hr was

wa ipl vrif pais iagsis r ifci sas. Hwvr,

assmig ha prvir kwlg is crrla wih halh car qali, a

iirc assssm f qali is pssibl b rviwig hw f prvirs

prscrib a apprpria rg fr a giv iagsis.

tabl 2 cais h prcag f isacs f a pariclar iagsis fr

which a apprpria rg was prscrib, fr sv f h ms cmm

iagss i h claims aabas. A rg was csir apprpria if

i cfrm a f hr isic b largl vrlappig saars:

h fficial prgram Saar f Car maal, h u.S. Crs fr

disas Crl a Prvi (CdC) tram Gilis, r h

rcmmais f a Wsr phsicia wih svral ars xpric

pracicig i h rgi. th prpri f apprprial ra iagss

rag frm 79 prc fr balaiis 98 prc fr grrha. tha

is, amg h 339 cass f balaiis iifi i h 19,656 pai visis,

79 prc rciv a ram ha was csir saar. this abl

prss xampl f hw s ri claims aa s aspcs

f qali i StI ram. th ms cmm iagss s i Figr 3

(sphilis, grrha, a caiiasis) wr ra crrcl mr f

ha rarr iagss. this fiig has implicais fr prgram pracic.th vchr maagm agc s ci whhr sffici

mbrs f pais wl bfi frm aiial prvir raiig

prpr ram f cmm StIs.

table 2: Percentage OF diagnOSeS (dX)

cOrrectly treated, by Patient ViSit FOr SeVen

Selected diagnOSeS amOng 19,656 Patient

ViSitS

doss a Vss Vs 1 Vs 2 Vs 3 Vs 4

% n % n % n % n % n

Balaiis 79 339 81 289 3 40 50 6 75 4

HSV 88 442 85 324 98 64 95 44 100 10

Bacrial Vagisis 79 110 77 86 85 20 100 4 0

Caiiasis 88 2,693 88 2,086 85 399 85 191 65 17

Grrha 98 5,823 98 3,488 99 1,589 99 683 90 63

Sphilis 95 10,386 95 6,622 95 2,443 99 1,198 62 123

trichmiasis 96 2,080 97 1,330 96 546 94 163 78 41

All Slc dx 95 21,873 94 14,225 95 5,101 97 2,289 73 258


23/28

23P4P


More than one diagnosis was given per patient visit. The percentage of

correctly treated drugs is higher for more common diagnoses.

Aalsis f srvic qali sig claims aa is scrib frhr i

Ax B.

dIStAnCe to CARe

disac frm hm cliic ca b a impra barrir car. Wh

sig p vchr prgrams acrss larg aras, prgram maagrs

b mifl f lcall accssibl faciliis a h css f

rasprai. A irsig xampl f h imprac f lcal accss

was ma wih h r f a w crac cliic 10 mhs afr h

StI prgram bga. I Figr 4, h map h lf shws h cmlaiv

mbr f pais b sbc frm Jl 2006 April 2007. n h

lw ilizai amg sbcis f shr Isigir isric, circl i

r, rlaiv hr sbcis lca arr crac faciliis.

Svral larg markig prsais wr cc vr h iiial

10 mhs i shr Isigir cmmiis, spi h fac ha

h ars cliic was l accssibl b ir ra i Mbarara w

Health clinic staff


24/28


30 kilmrs awa. th, a h f April 2007, Cliic Africa was

crac sablish a cliic i h mai w f Isigir isric. thr

mhs afr h facili p, vchr visis b Isigir isric rsis

icras ramaicall, as h righ ha map i Figr 4 shws.

Figure 4: change in utilizatiOn FOllOwing the

entry OF a new clinic in iSingirO diStrict in

aPril 2007

n: dspi scial markig i h circl rgi, ilizai rmai lw il h w cliic

p. this xampl highlighs h imprac f isac fr accss.

Ggraphic aa pais villag f rsic a cliic lcais wr

s masr h isacs ha pais ravl cliic. th isacfrm hm cliic has implicais fr iifig a rllig cliics

prvi srvics fr arg pplais. I is pssibl s h isacs

ha pais ravl fr halh car sima which pplais wl

b xcl frm h prgram i h fr bcas f isac. (Bcas

aa ra pahs ar lackig, all isacs ha b masr alg a

sraigh li, as h crw flis. thr is hs sm irc rrr, which

prscribs ail aalsis, b s alr h gral picr.)


25/28

25P4P


th StI claims aa shw ha ab 60 prc f pais visi a

cliic wihi 10 kilmrs f hir villag f rsic. Ma f hs

pais wr simpl visiig h ars cliic. Ab 55 prc f

all pais visi h ars cliic a h rmaiig 45 prc f

pais ravl a mr isa cliic fr hr pssibl rass: 1)h prfrr h mr isa cliic bcas f a qali r similar

characrisic, 2) h isac masrm was icrrc a h acal

r b ra was shrr, r 3) pais wr ravlig h farhr

lcai fr ahr ras.

usig h spaial a claims aa ss, i is pssibl masr cliic

prfrcs fr lcal aras a aswr qsis sch as: d all pais

frm a lcal ara visi ma cliics r l h ars ? Hw ma

people live in parishes within 1015 kilometers from more than one clinic

(a hrfr ma chs criria hr ha isac)? dfiiis

f wha is a rasabl isac ravl fr spcific halh srvics varbas h pgraph, raspr ssms, pai scicmic sas,

a p f halh srvic sgh.

external eValuatIon: changes In

Knowledge, BehAvior, CosT, And diseAseBurden

Wih sppr frm KFW i 2006, h la ahr f his brif a

h im a cral s a h uivrsi f Califria, Brkl

rk a xral impac valai f h StI vchr prgram icllabrai wih h Mbarara uivrsi f Scic a tchlg. th

valai masr h pplai impac f h prgram sig slc

iicars f kwlg, ilizai, cs, a isas br. I was bas

w pplai srvs f h grar Mbarara rgi, cc i

Jl 2006 a nvmbr 2007.

Aalsis f h srv aa prc svral irsig fiigs.

Kwlg f StI smpms icras 18 prc bw h firs

a sc ars (ajs s rai, aoR=1.43; 95 prc CI=1.22-

1.68). StI ram ilizai amg hs rprig havig ha

r mr StI smpms i h prvis six mhs icras 15 prci h sam pri; hwvr, h icras was saisicall sigifica

(aoR=1.14; 95% CI=0.89-1.47). th prvalc f sphilis, as masr b

h VdRL s, cras 42 prc bw h w srvs (aoR=0.63;

95 prc CI=0.48-0.79). thr was a grar rci i h prvalc

f sphilis amg rsps wh liv wihi 10 kilmrs f a

crac facili ha amg rsps wh liv mr ha 10

kilmrs frm a crac cliic (57 prc cras vrss 20

prc cras).


26/28


Th ugaa prgram has shw ha h vchr ml ca prvia rag f facili-bas halh srvics hsas f pais

pr ar. thr ar sigifica challgs, pariclarl wih claims

maagm. Hwvr, h challgs ffr ppriis lar

a mak imprvms i h ssm. th prgrams wl bfi

frm mr rigrs qali mirig a faciliis, mr accra

claims vig, a fasr rimbrsm. Mr grall, h vchrmaagm agc shl b iciviz cisl imprv h

qali f h prgram, b craivl sig availabl ifrmai, a b

slsl xpliig ppriis fr chags i prgram fci (.g.,

ircig markig icivs vchr isribrs r rwarig

faciliis wih high-qali labraris, r craig icivs fr h

VMA m ilizai gals r graig ciial las high-

prfrmig faciliis) ha cl imprv vrall fficic a fficac.

th lg-rm ssaiabili f bh prgrams rmais crai.

drs xpc ha prgrams shl bcm slf-ssaiig, a if h

vchr apprach is ci, h ugaa gvrm will

ak grar wrship f h vchr srvics. Alhgh h prgram

saw arl 20,000 StI pai visis i h firs 22 mhs f prais,

i icrr sigifica vrha css cmpar wih h ams

rimbrs prvirs. daabas vlpm a claims r

rprs vr -fifh (21 prc) f al prgram css whil

claims pams csi l 18 prc. nvrhlss, rs a

conclusIon


27/28

27P4P


gvrm wr sfficil saisfi wih h StI pil lach h

SM vchr prgram i 2008.

I is xpc ha h cs srcr i svral ars will rsmbl

ha f h Ka SM prgram, i which apprximal 80 prc fcss g prvir rimbrsm fr halh car livr (Bllws

al. 2009). thr wr w primar mivais bhi h vchr

prgram i ugaa: rcig h isas br asscia wih

StIs a maral livr a, b likig halh car srvics

rimbrsm, makig paricipaig prvirs mr accabl fr

qali. Frm h prspciv f h ugaa MoH, h vchr ml is

iq a valabl i ha i allws h gvrm rgla priva

scr halh car hrgh h s f fiacial icivs fr iivial

prvirs. thr is sigifica wrlwi irs i mls ha lik

halh car livr rimbrsm, a ugaas pblic-priva

parrship srvs as a ml fr hr gvrms csirig

sragis wrk mr clsl wih h priva scr.

Health clinic staff assist in processing claims forms to be

submitted to the Voucher Management Agency.


28/28

hat sytm 20/20 a -ya (2006-201cpat amt n. hs-A-00-06-00010-fu by t U.s. Acy f itatadpmt (UsAid). T pjct a ac, ac, pata, a capactybu ctat tat bck acc t a upty ppuat, at, a utt cby pp p cut.hat sytm 20/20 ff ba ap,tcca atac, ta, at, ac, afmat mat.

Abt Acat ic. (.abtacat.cm) a tam f pat tat cu:| Aa Ka Fuat | Bt y Aca | BrUty | Ba Bac Acat | dttCut, llP | Fum o Cmmucat| rTi itata |Ta ruc gup |Tua Uty sc f Pubc hat

disClAiMer: T aut xp t cay ct t f t U.s.Acy f itata dpmt t Ugmt.

F m fmat abut hat sytm 20pa ctact:hat sytm 20/20 | .atytm20Abt Acat ic. | .abtacat.cm4550 Mtmy la| sut 800 nt | Bta, Md 20814 | usae-ma: f@atytm2020.

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Photos: Ben Bellows and Melissa Ho

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