1. RH Vouchers and Health Systems Ben Bellows, PhD The Role of Vouchers in Serving Disadvantaged Populations and Improving Quality of Care November 6 th 2014 World Bank, Washington, DC

2. Overview Necessary conditions for successful RH voucher programs? Design characteristics of voucher programs? What is the coverage for RH voucher programs? How much would it cost to scale up RH voucher programs? How can vouchers fit into national objectives and international health goals?

4. Consider pre-conditions for scaled voucher programs POPULATION PROVIDERS HEALTH SYSTEM & GOVERNANCE

5. Population characteristics Gap in high quality RH service consumption Inequity in distribution of RH services & ability to pay Ability to identify target population Beneficiary’s agency on FP/RH issues (e.g. future-oriented, ability to make decisions, male support)

6. Health care provider characteristics Facilities must meet standards to be contracted – Tanzania (equipment to public facilities) – Cambodia (MOH QoC standards: pass, no pass) – Uganda (A, B, C) Routine quality improvement: QoC decreases are of concern Providers located in areas accessible to target population (transportation issues & marginal quality at remote facilities) Composition of providers – public/private – dual practice Capacity to treat and efficiency with increased volume of patients

7. Use of voucher reimbursements in Kenya 2009-2011 Construction Maternity wing; others Renovation and Repairs Maternity wing; other; sanitary (water, toilets etc) Human resources employment of doctors, nurses, support staff, salaries & wages, staff incentives, training Medical procurement Beds, nets, medical equipment, drugs, medical supplies Non-medical procurement Vehicle, land, furniture, water or power equipment, appliances, non-medical supplies Other recurrent costs Patient nutrition/meals, incentives to mothers, repair of medical equipment, service hire

8. Facility efficiency in provision of delivery services: Kenya

9. Government and health system characteristics Voucher management agency – autonomy – capacity to quickly & consistently disburse on time – measure quality – “trouble shoot” or innovate – Avoid over-centralized planning and adding burdens to existing agency without sufficient support Vouchers ought not to compete with existing programs with similar goals (e.g. Cambodia and health equity funds)

10. Coverage by RH voucher programs Country (DHS & program years) Total births % facility- based births (DHS) Births at poorest 40% HH % facility births for poorest 40% (DHS) Yearly vouchers issued Yearly voucher deliveries Voucher deliveries among all deliveries (yearly) Voucher deliveries among bottom 40% Cambodia (2010, 2013) 367,00053.8%146,80039.2% 9,248 5,8141.6%4.0% Bangladesh (2011, 2013) 3,401,00029.0%1,360,40013.7% 156,937 129,6163.8%9.5% Kenya (2009, 2013) 1,596,73343.0%638,69324.2% 53,404 45,3542.8%7.1% Tanzania (2010, 2013)* 1,813,38550.0%725,35434.7% 45,751 15,1600.8%2.1% Uganda (2011) 1,502,00057.4%600,80045.6% 58,397 31,0122.1%5.2%

11. Scaling beyond pilot programs for effective social protection: Kenya 2011 MOH budget US$465 million (41 billion KES) 2015 Deliveries among 40% poorest410,443 Service reimbursement $46,450,233 Program management $6,406,929 Total cost $52,857,161 Cost per maternal voucher $128.78

12. International health goals: UHC 1.Access: expand population covered 2.Scope: improve quality /quantity of health services offered 3.Financial protection: improve size of subsidies (or regulation of informal charges)

13. Conclusions Vouchers can work, but consider conditions and have an appropriate design Vouchers can be a responsive, scalable strategy to accelerate progress on global health priorities Incomplete evidence: – Do vouchers prime users and providers for a better understanding of insurance concepts? – How to standardize and validate equity measurement in voucher program operations (e.g. DHS quintiles)? – What “nudge” strategies can convert voucher holders to service users (e.g. lotteries, expiry dates)?

14. Thank you