Treatment vouchers- Giving the poor access to quality healthcare
May 17, 2009
ONCE beaten, twice shy, they say. Donors seem to know the adage only too well, after the Global Fund for HIV/AIDS, Tuberculosis and malaria scam, in which billions of shillings were swindled.
By Irene Nabusoba
ONCE beaten, twice shy, they say. Donors seem to know the adage only too well, after the Global Fund for HIV/AIDS, Tuberculosis and malaria scam, in which billions of shillings were swindled.
But now, with the output-based aid approach to healthcare provision or the voucher scheme in place, such scams could be a thing of the past.
The programme targets high-risk or low-income patients for critical healthcare services. It is managed by Marie Stopes International Uganda, an organisation that advocates quality reproductive health care, supported by the German Development Bank (KfW) and the Global Partnership on Output Based Aid of the World Bank. The system was introduced in the districts of Mbarara, Kiruhura, Isingiro and Ibanda in 2006.
The three-year reproductive health voucher project provides subsidised treatment of sexually transmitted infections (STIs) and safe maternal health services.
Thomas Mega, the Marie Stopes’ country director, explains that under the project, a patient gets a voucher to access subsidised medical care at an accredited health facility.
“The service providers return the vouchers to us after the client has accessed the services. After we have vetted the process to ensure that the clients received the services as agreed, we pay the provider the agreed sum,†Mega explains.
He says in the initial stages of the programme in the four districts, the system was only restricted to treatment of STIs but the current three-year project covers maternal care and builds on the successes of the earlier one.
This output-based form of aid is intended to address skewed service delivery by reimbursing clinics for services provided rather than services expected. The clinics are only paid for the patients seen.
Christine Namayanja, the programme director, says Marie Stopes organisation employs community members like village healthcare teams and community development officers, some of whom are attached to organisations working at the grassroots as well as local council leaders and opinion leaders, who are known by the population and understand the community.
“Particularly with the new voucher for pregnant mothers, we need these people to ensure that we reach the target group.
The poverty grading exercise is door-to-door and it is the local people who identify and screen the beneficiaries,†she explains.
What is the voucher?
The STI voucher is a double card that admits two people. It entitles one to counselling and education, diagnosis and four treatment schedules.
“We wanted to encourage couple screening to minimise re-infections,†she says. “We also wanted to use the visits to encourage behaviour change.â€
Namayanja says they discovered that the safe motherhood voucher, targeting pregnant women, was leaving out men.
Mega says through behaviour change communication campaigns, they encourage men to buy the vouchers for their wives and accompany them to hospital.
“These vouchers could ideally be free but we attached this small fee to encourage people to seek the service,†he says.
“Experience has shown that many people shun free services. They do not value them; they think they are substandard. With a fee, people will know the services are of good quality and will demand good care which forces service providers to step up their game.â€
It is a good bargain, considering that treatment of a single bout of an STI can cost between sh15,000 and sh30,000.
“We target all sexually active people with a particular focus on high-risk groups and the poor. We reimburse sh2,200 for each uncomplicated STI treatment,†Mega says.
A maternal healthcare voucher, on the other hand, entitles a pregnant woman to four antenatal visits inclusive of all necessary clinical interventions like HIV tests, scans and treatment of associated diseases; delivery-either normal or Caesarean section, transport in case of emergency to a referral hospital and one post-natal visit within one month after delivery.
By April this year, Mega says 28 mothers had benefited from the maternal healthcare component.
“We want to provide safe delivery services for 110,000 pregnant women and STI treatment for 35,000 clients,†he says.
“So far we are operating in four districts but we are targeting 23 districts although all this will depend on funding.â€
The average cost of a normal delivery is sh72,000 and sh308,000 for a complicated delivery which could call for a caesarean section, blood transfusion or ambulance services in case of referrals.
Achievements
Previously, with increased awareness on HIV/AIDS, STIs had been overlooked yet they are the commonest opportunistic infections. Namayanja argues that in instances of diagnosis, the Government encouraged treatment simply by basing on symptoms.
This affected drug adherence as patients were loaded with lots of medicines to take.
“In the process, health workers would miss the real conditions and this encouraged resistance to first line treatments for STIs.
We now emphasise clinical/laboratory tests to ascertain the condition before treatment is given,†she says adding that that they have so far distributed 11,000 vouchers and treated over 26,000 episodes of STIs for the period ending December 2008.
The programme has also trained voucher service providers in clinical diagnosis, laboratory diagnostic technique and differentiation between urinary tract infections (UTIs) and STIs, recommending treatment for both conditions.
“Few people had UTIs. Majority had STIs, with syphilis being the commonest. Cases of Gonorrhoea were reported to be rare but shot up after our intervention which means that probably we raised awareness and encouraged reporting,†she says.
The programme also sensitised over 121 communities on STIs and safe motherhood. “There is generally an improvement in health-seeking behaviour in the region.
Private clinics saw a 200% increase in STI patients both in the output-based aid and other clinics during the first year of the programme,†Namayanja says.
She argues that service providers are now more responsive to client needs and the male turn up is high because of the twin vouchers for STIs.
“Besides, there was hardly any monitoring or refresher training for the health workers. But after our intervention, many are appreciating retraining and are going back to school.
“We also improved the quality of services because we retrained lab assistants and assisted health units with lighting and some basic equipment to make the facilities fit for service delivery,†she says.
Challenges
The progress made has not been without challenges: “We had a problem with polygamous men. They would ask: ‘What of my other wives? This card admits only one,’†Namayanja says.
In addition, some areas do not have a private health centre within a radius of 5km.
“Some are too remote and all they have are health centre II or IIIs. But we do not work with Government facilities. We are limited to private health providers,†she says.
Mega notes that in this part of the country, many people believe in congenital syphilis. “Any rash is interpreted as so. Consequently, people who are screened for syphilis and test negative sometimes shun the hospital and resort to traditional healers.â€
Follow-ups, at 60%, have also been poor as patients hardly return once they are well. Departure of medical staff is also high undermining the quality of services.
“Some facilities have lost their trained personnel. Others are accredited but do not provide the services the way we agreed in the contract.
We have been forced to pay some of them less of what we had agreed on because of substandard services,†Namayanja says.“The programme calls for strict monitoring because if some service providers are not watched, they become fraudulent. â€
Inflating costs
Mega also notes that some service providers have a tendency of inflating the cost because they know this is a donor-funded project. “Communities have not learnt to own these programmes.
One told me, ‘I normally charge sh50,000 for delivery, but because this is a donor-funded project, we double the charges. You people have money’,†he recounts.
Another challenge is that some pregnant women do not want to be referred because they believe referral means they are going to be operated on.
“One of our clinics was recently stuck with a women, who had a complicated pregnancy but she refused to leave despite being referred. It was her first delivery in hospital, out of 13 pregnancies and she dreaded the idea of an operation since this is what a referral means to most of them,†Namayanja reveals.
So far, so good but the battle remains how to determine who benefits from the voucher. For some people, poverty is now a strategy to get free services.
How the voucher system works
Patients get vouchers from Marie Stopes, at sh3,000. They then access health services at contracted clinics in exchange for vouchers.
Christine Namayanja, the programme director, says the system involves collaborating with established and qualified healthcare providers to deliver high quality services.
“As the voucher management agency, we use the national recommended minimum standards to screen all the service providers to ensure that they provide quality services,†Namayanja says.
“We look at the location of the facility, physical structures, level and quality of staffing, equipment and drug stocks, hygiene and history of the quality of service delivery.
Those that fall short by small margins can be assisted to improve while those facilities that are in poor condition do not qualify for the contracts,†she adds.
ONCE beaten, twice shy, they say. Donors seem to know the adage only too well, after the Global Fund for HIV/AIDS, Tuberculosis and malaria scam, in which billions of shillings were swindled.
But now, with the output-based aid approach to healthcare provision or the voucher scheme in place, such scams could be a thing of the past.
The programme targets high-risk or low-income patients for critical healthcare services. It is managed by Marie Stopes International Uganda, an organisation that advocates quality reproductive health care, supported by the German Development Bank (KfW) and the Global Partnership on Output Based Aid of the World Bank. The system was introduced in the districts of Mbarara, Kiruhura, Isingiro and Ibanda in 2006.
The three-year reproductive health voucher project provides subsidised treatment of sexually transmitted infections (STIs) and safe maternal health services.
Thomas Mega, the Marie Stopes’ country director, explains that under the project, a patient gets a voucher to access subsidised medical care at an accredited health facility.
“The service providers return the vouchers to us after the client has accessed the services. After we have vetted the process to ensure that the clients received the services as agreed, we pay the provider the agreed sum,†Mega explains.
He says in the initial stages of the programme in the four districts, the system was only restricted to treatment of STIs but the current three-year project covers maternal care and builds on the successes of the earlier one.
This output-based form of aid is intended to address skewed service delivery by reimbursing clinics for services provided rather than services expected. The clinics are only paid for the patients seen.
Christine Namayanja, the programme director, says Marie Stopes organisation employs community members like village healthcare teams and community development officers, some of whom are attached to organisations working at the grassroots as well as local council leaders and opinion leaders, who are known by the population and understand the community.
“Particularly with the new voucher for pregnant mothers, we need these people to ensure that we reach the target group.
The poverty grading exercise is door-to-door and it is the local people who identify and screen the beneficiaries,†she explains.
What is the voucher?
The STI voucher is a double card that admits two people. It entitles one to counselling and education, diagnosis and four treatment schedules.
“We wanted to encourage couple screening to minimise re-infections,†she says. “We also wanted to use the visits to encourage behaviour change.â€
Namayanja says they discovered that the safe motherhood voucher, targeting pregnant women, was leaving out men.
Mega says through behaviour change communication campaigns, they encourage men to buy the vouchers for their wives and accompany them to hospital.
“These vouchers could ideally be free but we attached this small fee to encourage people to seek the service,†he says.
“Experience has shown that many people shun free services. They do not value them; they think they are substandard. With a fee, people will know the services are of good quality and will demand good care which forces service providers to step up their game.â€
It is a good bargain, considering that treatment of a single bout of an STI can cost between sh15,000 and sh30,000.
“We target all sexually active people with a particular focus on high-risk groups and the poor. We reimburse sh2,200 for each uncomplicated STI treatment,†Mega says.
A maternal healthcare voucher, on the other hand, entitles a pregnant woman to four antenatal visits inclusive of all necessary clinical interventions like HIV tests, scans and treatment of associated diseases; delivery-either normal or Caesarean section, transport in case of emergency to a referral hospital and one post-natal visit within one month after delivery.
By April this year, Mega says 28 mothers had benefited from the maternal healthcare component.
“We want to provide safe delivery services for 110,000 pregnant women and STI treatment for 35,000 clients,†he says.
“So far we are operating in four districts but we are targeting 23 districts although all this will depend on funding.â€
The average cost of a normal delivery is sh72,000 and sh308,000 for a complicated delivery which could call for a caesarean section, blood transfusion or ambulance services in case of referrals.
Achievements
Previously, with increased awareness on HIV/AIDS, STIs had been overlooked yet they are the commonest opportunistic infections. Namayanja argues that in instances of diagnosis, the Government encouraged treatment simply by basing on symptoms.
This affected drug adherence as patients were loaded with lots of medicines to take.
“In the process, health workers would miss the real conditions and this encouraged resistance to first line treatments for STIs.
We now emphasise clinical/laboratory tests to ascertain the condition before treatment is given,†she says adding that that they have so far distributed 11,000 vouchers and treated over 26,000 episodes of STIs for the period ending December 2008.
The programme has also trained voucher service providers in clinical diagnosis, laboratory diagnostic technique and differentiation between urinary tract infections (UTIs) and STIs, recommending treatment for both conditions.
“Few people had UTIs. Majority had STIs, with syphilis being the commonest. Cases of Gonorrhoea were reported to be rare but shot up after our intervention which means that probably we raised awareness and encouraged reporting,†she says.
The programme also sensitised over 121 communities on STIs and safe motherhood. “There is generally an improvement in health-seeking behaviour in the region.
Private clinics saw a 200% increase in STI patients both in the output-based aid and other clinics during the first year of the programme,†Namayanja says.
She argues that service providers are now more responsive to client needs and the male turn up is high because of the twin vouchers for STIs.
“Besides, there was hardly any monitoring or refresher training for the health workers. But after our intervention, many are appreciating retraining and are going back to school.
“We also improved the quality of services because we retrained lab assistants and assisted health units with lighting and some basic equipment to make the facilities fit for service delivery,†she says.
Challenges
The progress made has not been without challenges: “We had a problem with polygamous men. They would ask: ‘What of my other wives? This card admits only one,’†Namayanja says.
In addition, some areas do not have a private health centre within a radius of 5km.
“Some are too remote and all they have are health centre II or IIIs. But we do not work with Government facilities. We are limited to private health providers,†she says.
Mega notes that in this part of the country, many people believe in congenital syphilis. “Any rash is interpreted as so. Consequently, people who are screened for syphilis and test negative sometimes shun the hospital and resort to traditional healers.â€
Follow-ups, at 60%, have also been poor as patients hardly return once they are well. Departure of medical staff is also high undermining the quality of services.
“Some facilities have lost their trained personnel. Others are accredited but do not provide the services the way we agreed in the contract.
We have been forced to pay some of them less of what we had agreed on because of substandard services,†Namayanja says.“The programme calls for strict monitoring because if some service providers are not watched, they become fraudulent. â€
Inflating costs
Mega also notes that some service providers have a tendency of inflating the cost because they know this is a donor-funded project. “Communities have not learnt to own these programmes.
One told me, ‘I normally charge sh50,000 for delivery, but because this is a donor-funded project, we double the charges. You people have money’,†he recounts.
Another challenge is that some pregnant women do not want to be referred because they believe referral means they are going to be operated on.
“One of our clinics was recently stuck with a women, who had a complicated pregnancy but she refused to leave despite being referred. It was her first delivery in hospital, out of 13 pregnancies and she dreaded the idea of an operation since this is what a referral means to most of them,†Namayanja reveals.
So far, so good but the battle remains how to determine who benefits from the voucher. For some people, poverty is now a strategy to get free services.
How the voucher system works
Patients get vouchers from Marie Stopes, at sh3,000. They then access health services at contracted clinics in exchange for vouchers.
Christine Namayanja, the programme director, says the system involves collaborating with established and qualified healthcare providers to deliver high quality services.
“As the voucher management agency, we use the national recommended minimum standards to screen all the service providers to ensure that they provide quality services,†Namayanja says.
“We look at the location of the facility, physical structures, level and quality of staffing, equipment and drug stocks, hygiene and history of the quality of service delivery.
Those that fall short by small margins can be assisted to improve while those facilities that are in poor condition do not qualify for the contracts,†she adds.