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)?

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 xi as far as possible . Given this understanding of UHC, how important can vouchers contribution to UHC really be?

Figure 1: WHO's Universal Health Coverage 'Cube'

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

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

Program design & functions

Objective reach beneficiaries who in the absence of subsidy would not have sought equivalent care

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

Client
Poverty status & need? Voucher is free or fee? Which services offered?

Facility
Accredited? Clinical quality? Competition? Reimbursement rates?

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

30 25

20

15

Small (<$250k /yr) Medium ($250k$1m /yr) Large (>$1m /yr)

10

Program contracts with public & private providers

20 18 16 14 12 10 8 6 4 2 0 1 6 5 10 18

private

mostly private

mixed

mostly public

public

Evaluation outcomes (1 of 2)
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 (2 of 2)
Outcome type Number of Direction of effect & gaps in research studies

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

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 Study #1, Demand: Study of voucher

utilization in Kenya
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

Analysis

Cross tabulation with Chi-square tests Multilevel random-intercept logit analysis

()= + births by place of delivery over time

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 nonvoucher facilities

14

Change in place of delivery

2006 voucher arm Place of delivery Home Health facility Public facility Private facility p-value First survey 32% 66% 45% 21% Second survey 21% 79% 49% 30% p<0.01 2011 voucher arm First survey 59% 39% 32% 7% Second survey 47% 51% 36% 15% p<0.01 Comparison arm First survey 45% 54% 41% 13% Second survey 42% 57% 44% 13%

p=0.59

Adjusted odds ratios

Outcome Facility delivery 2006 2010-11 Comparison voucher arm voucher arm arm 2.04** (1.40-2.98) 1.72** (1.22-2.43) 0.61** (0.43-0.85) 1.32 (0.96-1.81) 0.75 (0.54-1.03)

Home delivery 0.53** (0.36-0.78)

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

40% 35% 30% 25% 20% 15% 10% 5% 0% 33% 35%

9%

11% 6%

7%

Revenue source before vouchers program

Revenue Public Private Source Facilities Facilities Prior to the GoK Voucher program Government 50% 0 57% 43% 0 Self-generated 31% revenue FBOs 0 53% 0 37%

Bank Loans Donors

0 19%

81% of the facili7es reported that following the launch of the voucher program, the voucher program has been their main revenue.

Facilities also reported

Challenges in accessing and purchasing medical and non- medical supplies. Voucher revenue used to: 1. Cover the nancing 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 nancing gaps to provide beMer healthcare services.

In a scaled vouchers strategy that moves us toward UHC, which tradeoffs 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 xi as far as possible . Given this understanding of UHC, how important can vouchers contribution to UHC really be?

Figure 1: WHO's Universal Health Coverage 'Cube'

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

Think like a demographer. An incremental allocation could take vouchers to scale

US$ millions Service delivery cost Management cost (15-20%) Total cost: Maternal voucher % MOH 2011-12 budget $813m Family planning service cost Management cost (15-20%) Total cost: FP voucher % MOH 2011-12 budget $813m 70% coverage of 2 lowest quintiles 2013 23 3 27 3.3% 16 3 19 2.3% 2014 29 6 35 4.3% 17 3 20 2.5% 2015 32 6 38 4.7% 20 3 22 2.7%

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

UHC & vouchers- Financial protection

Voucher clients receive a subsidy and avoid paying out-of-pocket at point-ofcare 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

26

Thank you

RHVouchers.org @benbellows bbellows@popcouncil.org