1. Targeting vouchers to underserved populations in Nicaragua Central American Health Institute - ICAS Anna Gorter Julienne McKay Liesbeth Meuwissen Zoyla Segura Joel Medina Ben Benjamins

2. Outline of presentation General: voucher schemes in Nicaragua Results evaluation sex worker program Results evaluation adolescent program Discussion Conclusion

3. Why use vouchers Nicaragua second poorest country in LA Pronounced health system failure to serve needy and vulnerable population groups –even if services are associated with positive externalities, e.g. HIV/AIDS services for sex workers or family planning for young people Search for alternative approaches

4. ICAS and vouchers Voucher development initiated in 1995 Process of learning by doing First pilot (’95 – ’98) for sex workers successful Funding obtained: –continuation of vouchers for sex workers and other populations at risk for HIV –initiated programs for sexual and reproductive health for poor urban adolescents 2005: ICAS developed the World Bank ‘Guide to Competitive Vouchers in Health’

5. Two voucher programs presented Populations at risk for HIV (’95-ongoing): Poor urban adolescents at risk (’00-’05): Programs implemented in major cities of Pacific Coast and some smaller

6. Major Cities included: Chinandega Leon Managua Rivas

7. V O U C H E R V O U C H E R Clients/partners Friends V O U C H E R V O U C H E R Sex worker and adolescent voucher schemes

8. Voucher distribution By trained health promoters: from ICAS or where possible, from NGOs or third party At sites where targeted populations found (prostitution sites, markets, poor barrios, public schools etc) Health promoters explain carefully why, what, where

9. Voucher distribution adolescents

10. Services provided All services provided free of charge Populations at risk of HIV: –Counselling, condoms, educational material –STI treatment: presumptive (gonorrhoea, chlamydia) based on lab tests (syphilis, trichomonas) –HIV testing + referral to HIV/AIDS services Poor adolescents: –Counselling (on issues according to need) –Family Planning –Pregnancy testing, first prenatal control –STI diagnosis and treatment

11. Monitoring Clinic Performance and quality of care Medical record review Voucher redemption rates at each clinic Follow-up consultation rates at each clinic Interviews with voucher users: –Sex workers: street interviews with 10% of female voucher redeemers –Adolescents: mystery patients

12. Overall results 1995-2008 Around 50 clinics contracted (mostly NGO) Almost 150,000 vouchers distributed 37,376 medical consultations provided

13. % of vouchers used of the total number of vouchers distributed Type of population% of vouchers Populations at risk of HIV (’95-’08)37%  Sex workers45%  Males (partners, clients)33% Poor adolescents (’00-’05)20%  Female25%  Male13%

14. Impact evaluations Prospective cohort study to assess impact on reduction of STIs in sex workers of Managua (1996-2005) Quasi-experimental intervention study to assess impact on use of family planning methods by adolescents of poor barrios of Managua (2000-2001)

15. Some details of the sex worker program in Managua 1996-2005 Voucher distribution in rounds at all known prostitution sites in Managua 2 - 3 rounds/year according to financial means (average of 1,050 vouchers/round) 21,920 vouchers distributed in 21 rounds 10,100 consultations to sex workers 3,500 STIs treated (syphilis, gonorhoea, chlamydia, trichomonas)

16. Reduction of syphilis and trichomonas in sex workers of Managua in 21 rounds

17. Evidence that program lowered STI prevalence Irregular funding led to variations in time periods between rounds (3 to 9 months). Highly statistically significant relationship between these variations and changes in STI prevalence, allowing attribution of the reduction in STI prevalence to the voucher program. Other trends did not add anything to the highly statistically significant relationship between changes in time periods and changes in STI prevalence.

18. Relation between timing of treatment rounds and measured STI prevalence at start of each round (long periods between rounds – high bounce back of STIs) 0% 5% 10% 15% 20% 25% 30% 35% 0123456789101112131415161718192021 Round Measured STI Prevalence McKay et al, AJPH 2006;96:7-9

19. Impact evaluations Prospective cohort study to assess impact on reduction of STIs in sex workers of Managua (1996-2005) Quasi-experimental intervention study to assess impact on use of family planning methods by adolescents of poor barrios of Managua (2000-2001)

20. Adolescents Voucher Program Managua 2000-2001 Adolescents face many barriers to access sexual and reproductive health services. High rates of: –Early and unwanted pregnancies, maternal morbidity and mortality, STIs, including HIV Vouchers were distributed and 20 clinics contracted and staff trained To investigate impact, a random sample of 3,009 female adolescents filled a self-administered questionnaire in 2001

21. 3,009 interviews 904 voucher receivers 2,105 non-receivers The 2 groups were compared Girl at market filling her questionnaire

22. Impact of vouchers on knowledge and practices % Outcome Non receivers Voucher receivers Adjusted Odds Ratio (CI) * Use of SR health services 19%34% 3.1 (2.5-3.8) Use of family planning methods 50% 1.3 (0.8-2.3) Knowledge of STIs 37%49% 2.6 (1.6-4.1) Use of condom in last sexual contact 20%23% 1.8 (1.1-3.0) * Results of multiple logistic regression model (Meuwissen et al, JAH, 2006)

23. Impact on use of services by subgroups

24. Overall results adolescent vouchers Voucher receivers had much higher use of SR health services (34% versus 19%) Family planning use increased most in voucher receivers at schools (48% versus 33%) Condom use at last sexual contact increased greatest in girls with little education (29% vs 14%) Satisfaction with services was higher in users- with-vouchers compared to users-without- vouchers (AOR=2.2, CI 1.2-4.0)

25. Most relevant lessons from impact studies Vouchers encouraged use of services by: –Removing financial barriers –Providing information (why, what, where) –Guaranteeing proper treatment Vouchers empower clients by allowing them to go to the clinic of their choice: –Clinics given incentive to be responsive to clients

26. Conclusion Vouchers increased the use of priority health services among two needy and underserved populations The use of health services had a positive impact on the health status of both populations: –reducing STI prevalence –assisting in containing the spread of HIV –Increase in use of contraceptives, thereby reducing the high number of unwanted pregnancies

27. For more information www.icas.net

31. END Next slides can be used for the general introduction on vouchers at the beginning of the panel

32. SUBSIDIES Eg. Tax revenue or donation SUPPLY SIDE FINANCINGDEMAND SIDE FINANCING PROVIDER ORGANIZATION Eg. MoH, Social Security, other. PAYMENT ORGANIZATION Eg. Voucher Agency INPUTS Eg. Salaries, Drugs, etc RIGHT TO SUBSIDY Eg. Vouchers, capitation payment, fee subsidies PROVIDERS USERS Free or subsidized services Redemption of the right for subsidy USERS PROVIDERS Payments Invoice for Subsidies on Goods and /or services Co-payments

33. Competitive voucher scheme in health Voucher Voucher agency Voucher recipients Service Providers (compete for vouchers) Donor/ Government Voucher $ $ Training plus performance monitoring M&E reports

34. 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

35. Encourage use (incl. of services with positive externalities) When demand is limited by barriers to access (cost, lack of knowledge, stigma..) Vouchers inform about services and guide users to where services can be obtained Remove cost barriers (incl. eg transport costs) Power of choice increases client satisfaction –Encourages use –Positive experience leads to repeat use –‘Worth of mouth’ recommendation to others

36. Vouchers can increase efficiency & service standards Increased utilization of private sector resources Reduced input costs Competition between participating providers (private, NGO, public) : –Reduced price –Increased service quality –Increased clients satisfaction

37. Impact on quality Because of quality specifications in contracts Also because contracts require staff: –to receive training and –employ evidence based ‘best practice’ protocols Competition improves overall attractiveness (staff more friendly and non-stigmatizing) Worst performing providers are removed

38. Increased equity Because vouchers remove cost and quality barrier to service uptake Because vouchers can target the poor Because there is an additional self-selection by those with the greatest needs E.g. amongst sex workers it were the poorest and most needy who made much more use of their voucher (glue-sniffing street youth and poor sex workers from the markets)