1. Scaling up a successful research project to reach vulnerable populations with STI/HIV care through a competitive voucher scheme in Nicaragua Anna Gorter Zoyla Segura Esteban Zuñiga Joel Medina ICAS-Nicaragua www.icas.net Financed by the Dutch Embassy and NOVIB

2. HIV prevention and STI/HIV care for vulnerable populations Vulnerable populations have limited access to STI/HIV care because of: –Costs, distance, time –Stigmatizing –Low human and technical quality Need for client-friendly quality care However –Accessible quality care is expensive –Limited resources should be targeted

3. Competitive voucher schemes Competitive vouchers can target limited resources to vulnerable populations for the provision of clearly defined packages of services, eg. quality STI/HIV care Competitive vouchers are a type of demand side financing

4. Demand Side Financing Competitive Vouchers Scheme Supply Side Financing Current System (Inputs) High Consumer empowerment Low Good Targeting Poor High Choice Low/No High Provider Competition Low/No Demand side financing compared to Supply side financing

5. What is a voucher A document which can be exchanged for defined goods or medical services as a token of payment Example of voucher The voucher empowers the consumer, who can choose among different health care providers to redeem the voucher

6. Voucher program in Managua Started as research project to prevent HIV by targeting quality STI care to sex workers (SW) 1995-1999 (female SW, transvestite and glue-sniffers) Contracts 10-12 clinics through competitive tender Trains clinic staff Distributes vouchers at all prostitution sites (2x/year) Uses protocols: combination of presumptive treatment with zitromax, tests, clinical diagnosis; safe sex education and material; condoms Pays clinics according to number of SW attended Monitors quality and only best clinics are retained

7. Vulnerable groups Clinics Voucher Agency ICAS Donor/ Government V O U C H E R V O U C H E R Clients & Partners V O U C H E R V O U C H E R V O U C H E R

8. From research to program Research project successful in reaching sex workers: –Almost half of sex workers used their voucher –Greatest voucher use by those with the highest STI rates, who are also the poorest, including glue-sniffers Decrease STIs in sex workers redeeming their voucher, annual reduction of prevalence: –9% for trichomonas –8% for gonorrhoea –16% for syphilis Its success led researchers to turn project into an operational program

9. Scaling up the voucher program Scaling up occurred in several phases: Inclusion of other populations: –Clients/partners of sex workers (1999) –Men who have sex with men (including prisoners) 2001 –Mobile groups: truck-drivers, military (2002) More services: HIV testing, follow-up HIV + (2001) Expansion to 3 other departments (2002-2004)

10. Results over 9 years > 20 clinics contracted (public, private and NGO) > 50,000 field contacts (promotion safe sex, STI control; distribution of condoms and vouchers) ½ of female and ¼ of male vouchers redeemed > 16,000 medical consultations for STI/HIV care, with 5,600 alone over 2003

11. Reaching vulnerable groups with STI/HIV care successful The program could attract difficult-to-reach, vulnerable populations in all departments Additional self-selection effect: greatest voucher use by those with highest STIs rates (‘super targeting’) Within the vulnerable groups, the program: –reduced STI rates and increased condom use –Increased access to quality VCT for HIV –Improved follow-up of HIV+ members

12. Reduction STI’s in sex workers who used a voucher 3 times or more

13. HIV prevalence in sex workers Managua remained low HIV prevalence: 1991: 0.8% 1996: 1.5% 1997: 1.3% 1999: 2.0% 2000: 0.9% 2002: 0.4% Sex workers in nightclub

14. Lessons learned in developing program to present scale Start-up costs were high but declined over time Setting up is complex, takes time to develop Uses existing clinics, no need for new services Mobilizes private sector into STI/HIV care Uses competition to minimize costs Obtains quality STI/HIV care because of –Competition and compulsory training of staff –Use of treatment protocols –Retaining only best performing clinics in program

15. Conclusion Targeting STI/HIV care through competitive voucher programs is highly effective in reaching vulnerable groups Once established, the program is easy to run. Furthermore it proofed easy to scale up: –to other vulnerable populations groups, –to include other priority services e.g. HIV testing –to other departments of Nicaragua

16. More information: www.icas.net agorter@ibw.com.ni