Can Demand Side Financing, e.g.
vouchers, assist Governments to reach
MDGs and reduce Maternal Mortality?
Anna C. Gorter, MD, PhD
Instituto CentroAmerica de la Salud
www.icas.net
Voucher Baby
Video Conference WHO, Port Moresby, PNG, September 8, 2010
Outline of presentation
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Demand-side versus supply-side financing
Examples of demand side financing
What are voucher schemes
Potential strengths of vouchers
Experiences from vouchers providing safe
motherhood services
Lessons learnt and conclusion
HEALTH FINANCING
e.g. Tax revenue or donation
PAYMENT ORGANISATION
e.g. Ministry of Health
INPUTS
e.g. salaries,
medicines,
equipment,
etc
PAYMENT ORGANISATION
e.g. Voucher Agency
RIGHT TO
SUBSIDY
e.g. Vouchers,
fee
subsidies
Payments
PATIENTS
HEALTH FACILITIES
Free or
Co-payments subsidized
services
PATIENTS
SUPPLY SIDE FINANCING
Invoice for
Subsidies on
Goods and /or
services
Redemption
of the right
for subsidy
HEALTH FACILITIES
DEMAND SIDE FINANCING
Supply Side Financing
ADVANTAGES
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Simple to introduce
Cheap to administer
Best when the health
services are actually
used by the patients
who need the services
DISADVANTAGES
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Difficult to target patients
who need the services but
currently do not use these
Low incentive to increase
the number of patients
Low incentive to provide
services according to the
needs of the patients
Demand Side Financing (DSF)
Two forms
Patient gets subsidy
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The subsidy is given
directly to the patient
Health facility gets subsidy
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The subsidy is given to
the health facility based
on a contractual
arrangement
Examples DSF where the health
facility gets the subsidy
 Fee-for-service
subsidy claims
 Referral vouchers
 Others, e.g.
Cost-per-case contracts
 Capitation payments
 Target payments
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Examples where the patient
gets the subsidy
Given before the health
service is used
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Cash payment to patients
Contributions to family
medical savings schemes
Vouchers
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Competitive
Non-competitive
Given after the health
service is used
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Cash refunds
Conditional cash
transfer (incentive
based voucher)
What is a voucher
A document which can be exchanged for
defined goods or medical services as a
token of payment
OR
"Tied cash
(as opposed to liquid cash)"
Some examples of vouchers
Voucher scheme
Voucher
agency
Step 1
$
M&E reports
Step 2
Voucher
Step 4
Donor/
Government
Voucher $
Health
Facilities
Target
population
Voucher
Step 3
Important to note
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Voucher programmes can contract all health
facilities capable and willing to provide the
services (public, mission, NGO and private
health facilities)
They can function hand in hand with supply
side financing of the health facilities
They can be used as a temporary measure to
quickly increase the use of a priority services,
such as safe motherhood
Strengths of vouchers
Targeting of population sub-groups
 Encouraging use of particular services
 Can improve quality
 Can increase efficiency
 Payment for services which are actually
provided
 Facilitates monitoring and evaluation
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Targeting
Is a strength when beneficiaries can easily
be identified, e.g.
 Groups who fear stigmatization
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people with TB, Leprosy, AIDS
Groups who need priority health
services, but do not use them, e.g:
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Adolescents, young people in need of Sexual and
Reproductive Health
Poor pregnant women in need of safe motherhood
services
Vouchers encourage use of
important health services
When use is limited by barriers to access
(cost, lack of knowledge, cultural
barriers..)
 Remove cost barriers (incl. eg transport
and food or other costs)
 Vouchers inform about services and
guide users to where services can be
obtained
Vouchers can increase quality
and efficiency
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Quality of services is improved because
vouchers incentivise the health facility to
respond to the needs of the patients:
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e.g. friendly services, ensuring medicines are
available, equipment is working etc
Efficiency is increased because only services
which have actually been provided, are paid
for. This can increase the number of patients
using the health facility
Some examples of impact of
voucher schemes for safe
motherhood
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Kenya
India
Bangladesh
Kenya voucher scheme,
started June 2006
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Financed by the German Development Bank KfW
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Poor in 3 rural districts, 2 urban slums Nairobi
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To increase access to safe motherhood, family
planning and gender based violence services
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Public, mission, private, and NGO providers
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Voucher agency is PriceWaterhouseCoopers
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Vouchers are sold at highly subsidized prices
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Over 100,000 vouchers used (especially safe
motherhood vouchers)
Increase in percentage of deliveries
in a health facility in Kenya
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
90%
71%
DHS all
54%
DHS illiterate
44%
Nairobi slums
15%
23%
Voucher areas
Institutional deliveries
Kiambu
Kisumu
Kitui
Percentage of deliveries in a health
facility with and without
voucher schemes (India)
Evaluation voucher scheme in
Bangladesh, some findings
60%
55%
50%
40%
38%
34%
36%
30%
Control
19%
20%
21%
10%
0%
ANC
Delivery in facility
PNC
Voucher
Lessons learnt
What makes vouchers successful?
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Appropriate design, committed stakeholders
Independent Voucher Management Agency, i.e.
a third party which is able to defend the rights of
the patients
Efficient management procedures
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smooth payment of health facilities
Vouchers address priority health services
Vouchers address specific barriers to access
health services (costs, lack of information etc)
Some potential drawbacks of
vouchers
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Design and set-up is complex (devil is in the
detail), needs training of staff at the start
May be susceptible to abuse (black market of
vouchers, collusion between health facilities
and distributors..)
Program development may take time
However once established vouchers are easy to
run and to scale-up, and costs go down
Conclusion I
 Vouchers
do not replace supply side
financing, but strengthen the
functioning of health facilities
because they motivate staff to
produce more and better services
Conclusion II
 Vouchers
are very good at increasing
the use of safe motherhood services
by women who currently do not use
these services
 Great potential in helping to reduce
maternal morbidity and mortality
CAMBODIA
EXAMPLE IF TIME PERMITS
Cambodia voucher schemes
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Successful voucher scheme in MoH facilities in
Kampong Cham province (Feb 2007):
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Targeting poor pregnant women
Reduced financial barriers to deliver at facility
Made health facility more responsive to women
New voucher scheme financed by the German
Development Bank (KfW):
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Three provinces providing safe motherhood and safe
abortion services as well as family planning services
Results from Cambodia