13. mch voucher scheme and hospital equity fund

MCH Voucher Scheme and Hospital Equity Fund : An Update

Financing Schemes : Health System Strengthening

Dissemination on Implementation of Health Systems Strengthening in (20) Townships MOH Meeting Room, Nay Pyi Taw, Myanmar, 6th August 2012

Financial barriers is a fundamental problem in

improving access for mothers and children

during health systems assessments

HSS funds have been identified to remove

these financial barriers

In Yedarshay, the concept of “Maternal and

Child Health Voucher Scheme” (MVS) has been

developed to improve access by the poor to life

saving pregnancy related referral and

treatment services

All poor pregnant women and the newly

born infants especially those residing in

hard-to-reach areas

Health care providers as regards rural and

urban

(4) AN Care

Normal delivery with SBA at home or at health

center

Management of complications

Food cost, lodging cost, travel cost and direct

medical care cost covered by Hospital Equity

Fund

(1) PN care

Summary: budget for MCH Voucher Scheme

Point of service delivery

4 ANC +PNC DeliveryTotal

For pregnant women

For providers

For pregnant women

For providers

Services at home

1,000 k 4,000 k +1,500 k

5,000 k 11,000 k 22,500 k

Service at health facilities

8,000 k 4,000 k 10,000 k 10,000 k 32,000 k

Estimated service uptake according to the revised plan

ANC with SBA

Delivery with SBA

Baseline 73% 51%

Revised plan

93% - 100% 59% - 67%

Yedashe

Village

MoHManagement agency

Township Hospital

Health facilities

VV

V

VV

V

V

V

VV

VV

VV

Outreach

Over utilization

Multiple voucher

distributors

V

V

Administrative burden

Financial management process

Healthcare providers

• Register pregnant women.• Provide MCH services stated in the benefit

package to pregnant women with the vouchers.

• Submit the providing services forms (P1), summary of the service provision forms (P2), and vouchers to management agency for reimbursement on a monthly basis.

Health facilities

DistributorsDistributors Management Agency

MonthlyV1i

Monthly

Not more than 2 weeks

P1i

P2i M1

i

M2i

• Verify the documents submitted by voucher distributors and healthcare providers (V1 vs P1) .

• Disburse the expenditures to distributors and healthcare providers without delays (2 weeks), along with the summary of the disbursement forms (M1).

• Report the activities and financial statement to the MoH on a quarterly basis (M2).

• Performance evaluationHealth facilities

Management agency

Levels Process Outputs/outcomes

Immediate Intermediate Final

Health Economics

Population • Number of voucher distribution

• Awareness• Attitude• Trust

• Utilisation of MCH services• Proportion of voucher reimbursement

• Maternal/Infant morbidity & mortality

• Value for money

Providers • Satisfaction• Participation• Adherence to the protocol

• Awareness• Attitude• Trust

• Quantity & quality of services provided• Capacity building

- • Financial space

Household/ individual

• Satisfaction • Awareness• Attitude• Trust• Knowledge

• Utilisation of MCH services

• High risk pregnancies received proper care

• Reduction of household expenditures

+ Program performance evaluation

Monitoring and Evaluation

What is the high priority measures?

• Monitoring for service utilization– Number of vouchers distributed– Number of voucher utilization

Source of data: from VD1 and P1 formSource of data: from VD1 and P1 form

• Adherence to the protocol– Completeness, average and range of

disbursement process

Source of data: from P1 and M1 form, monitor q 3-6 months if possibleSource of data: from P1 and M1 form, monitor q 3-6 months if possible

• Cost of programme implementation– Reimbursement cost of providing ANC at home/health

facility– Reimbursement cost of providing delivery at home/health

facility– Reimbursement cost of providing PNC at home/health

facility

Source of data: from reimbursement records Source of data: from reimbursement records

What is the priority measures?

• Costs of programme implementation– Costs of voucher production– Costs of distribution of voucher– Costs of voucher reimbursement system– Costs of administrative tasks – Costs of communication campaigns– Costs of human resource training

Source of data: from management agencySource of data: from management agency

• Costs of programme implementation (HEF)– Reimbursement cost of complication management– Reimbursement cost of providing caesarean section

including medicines– Reimbursement cost of transportation to referral facility

Source of data: from reimbursement recordsSource of data: from reimbursement records

What is the priority measures?

Performance evaluationIndicators Sources of dataVoucher distribution/ utilization rate (also by services) V1 and P1

Payment by items (Medical cost, incentive cost, administration cost)

M2

Time to completed disbursement process ( Completeness, average and range)

P1 and M1

Reimbursement of the provider requests(% full amount, gap)

P2 and M1

Frequency of internal account audits (6 months)

MoH staff audit

Satisfaction of the financial process? Survey (Pregnant women, distributors and healthcare providers)

Hospital Equity Fund (or) Patient Referral Fund for poor mothers and

childrenGAVI HSS

Health systems assessments conducted in Myanmar between 2009 and 2011 in 20 HSS Townships

• Financial barriers to access- have been identified as a fundamental problem in improving access for mothers and children

• HSS funds have been identified in order to assisting with removing these financial barriers.

• In the Township of Lewe, the concept of a “Patient Referral Fund” has been put forward in the CTHP to improve access by the poor to life saving referral and treatment services at the Township Hospital.

HEFObjectives: • To enhance access by the poor mothers and children to

hospital based services, through provision of targeted medical allowance for emergency transport and emergency and life saving procedures at the Township Hospital.

Expected Outcomes/Output• With this fund support, could save the lives of poor

mothers and children, – who are difficult to access to hospital (physically or

economically)– by getting timely referral and treatment,

Beneficiaries

• All emergency patients (mothers and children under 5 pre identified as poor) with life threatening conditions (this includes classifications of mothers or children as being at “high risk” of a life threatening condition).

• Mothers and pregnant women and children 0 – 5 of a specified income level (post identification for eligibility) at entrance of hospital

Benefits Package• Emergency procedures (such as cesarean section

and other life saving procedure)• Management of Complicated delivery (eclampsia,

obstructed delivery, APH and PPH and abortion related complications)

• Other life saving emergencies (e.g. RTA and snake bites and others)

• Management of Child hood acute illness (e.g. peummonia, diarhhoea, dengue and malaria or other acute condition)

Details of Benefits

• Reimbursement of medicines and related costs (procedures) and transport and food costs

• 5 – 10 days stay in hospital with one attendant • Total reimbursement not exceeding 100,000 kyats

for the whole benefit package

• The option should be considered for forwarding part of the referral fund to selected RHC for emergency transport, to be overseen by the RHC supervisory committee.

HEF Fund Holders According to the guideline flow of this Hospital Equity

Fund will be supervised by budgetary sub-committee under the township health committee.

The Budgetary sub-committee is organized by –• Local well wisher who involve in the township health

committee - Chairman• Gazette officer from the District/Township Health

Department - Member (1)• Local well wisher - Member (2)• District/Township Medical Officer - Secretary• Accountant

Assessment of Eligibility for Benefits

• Eligibility for benefits should be based on pre identification of income/asset status.

• This should be accessed through – Using social mapping methods, – community leaders, local authorities and elders

should assess and select the village areas and households with the “most poor status.”

– Through package tour by group of BHS for identification of poor mothers and children

Reporting and Auditing• Support can be provided through the Hospital Supervisory

Committee and Township Auditors Office for Reporting.

A Patient Referral Fund (PRF) Report form should be completeddetailing:• Name and address of beneficiary• Medical Condition• Benefits provided (Medicines, Food and Transport,

procedures)• Attachment of pre identification questionnaire• Signatures of patient/family of patient and of Chair of

Hospital Supervisory Committee or other non medical member.

Estimated Budget for one patient:• Transportation cost for emergency referral of patient = 35,000 Ks • Treatment cost (Drug cost + other treatment cost) = 40,000 Ks • Perdiem – 3,500 Ks x 8 days (during the hospital stay) = 28,000 Ks

103,000 Ks

• For 1 township = (6-7) patients/mth x 12 mths = 80 patients for one year

• For 1 township = 103,000 Ks/pt x 80 patients = 8,240,000 Ks = other incidental cost = 10,000 Ks

8,250,000 Ks

HEF funds distributed to 20 townships in May 2012

Budget used status as of July 2012

• Townships that have not started using HEF= 5

• Townships that have used HEF = 15

Kawt Hmu Township, May 2012SN Patient's Name Age/ Sex Treatment Cost (kyats)

1 Daw Kyin Mya, APH

46, F Em. LSCS Drug cost- 31625TA – 35000DA (pt+1) -2x2000x7D= 28000Total - 94625

2 Su Su Hlaing, Breech presentation

24, F Em. LSCS Drug cost- 31625DA (pt+1) -2x2000x7D 28000Total - 59625

3 Ma Myint TheinHydraminos, baby congenital abn

31, F Em. LSCS Drug cost- 20900TA – 30000DA (pt+1) -2x2000x7D 28000Total - 78900

4 Nu Nu Win 30, F Normal labour

Drug cost- 6725DA (pt+1) -2x2000x4D 16000Total - 22725

Total 255,875

Kawt Hmu Township, May 2012SN Patient's Name Age/ Sex Treatment Cost (kyats)

1 Pyae Pyae Aung 4, F Acute GE Drug cost- 1525 DA (pt) -1x2000x3D= 6000Total - 7525

2 Phyo Ainga 4 mth, F Acute GE Drug cost- 4300DA (pt+1) -2x2000x3D 12000Total - 16300

3 Saint San Yae 3 1/2, F Acute Viral infection

Drug cost- 2100DA (pt+1) -2x2000x3D 12000Total - 14100

Total 37,925

Grand Total 293,800

Ngaputaw Township, May 2012SN Patient's Name Age/ Sex Treatment Cost (kyats)

1 Naw Aye Thaw , F Normal Labour

Drug cost- 46925 DA (pt) -2x3000x7D= 42000Total - 88925

2 Ma Khin Hmwe , F Normal Labour

Drug cost- 55925

Grand Total

144850

HEF Expenditure for May SN

Townships No of Patient

DA TA Drug Cost Total Cost

(kyats)

1.Kawthmu 7 130000 65000 98350 293350

2.Ngaputaw 2 42000 102850 144850

Total 172000 65000 201200 438200

Unit Cost: 48,689

HEF Expenditure for JuneSN

Townships No of Patient

DA TA Drug Cost Total Cost (kyats)

1Bamaw 5 147000 115000 219500 481500

2Shwegu 7 196000 64000 173000 433000

3Hlaingbwe 4 66500 69000 166445 3019454Mudon 6 133000 210000 157000 500000

5Kyaingtong 3 84000 70000 87250 2412506NyaungShwe 3 88885 66500 24000 179385

7Hsipaw 2 67400 67400

8Kawthmu 2 68000 20000 62950 1509509Htilin 6 126000 12000 138000 276000

10YeOo 1 0 0 57405 5740511Myeik 3 84000 105000 111000 30000012Ngaputaw 5 95860 95860

Total 47

993,385 731,500

1,359,810 3,084,695

Unit Cost: 65,632

HEF Expenditure for JulySN

Townships No of Patient

DA TA Drug Cost Total Cost (kyats)

1Bamaw 12 252,000 247,000 498,800 997,800 2Shwegu 12 291,000 165,000 111,000 567,000 3Demawsoe 1 28,000 10,000 37,000 75,000 4Hlaingbwe 3 59,500 50,000 113,600 223,100 5Hakha 3 80,500 76,000 128,500 285,000 6Thaton 2 58,000 45,000 128,500 231,500 7Mudon 7 136,500 175,000 160,220 471,720 8Kyaingtong9Hsipaw 3 10,500 5,000 32,700 48,200

10Kawthmu 2 52,000 45,000 29,250 126,250 11Htilin 8 126,000 160,000 232,000 518,000 12YaeOo 1 44,394 44,394 13Myeik 2 38,500 55,000 74,000 167,500 14Ngaputaw 10 20,000 190,095 210,095

Total 661,152,500

1,033,000

1,780,059 3,965,559

Unit Cost:60,084

HEF Expenditure Total For 3 months SN Townships No of

Patient DA TA Drug Cost Total Cost

(kyats)

1Bamaw 17 399,000 362,000 718,300 1,479,3002Shwegu 19 487,000 229,000 284,000 1,000,0003Demawsoe 1 28,000 10,000 37,000 75,0004Hlaingbwe 7 126,000 119,000 280,045 525,0455Hakha 3 80,500 76,000 128,500 285,0006Thaton 2 58,000 45,000 128,500 231,5007Mudon 13 269,500 385,000 317,220 971,720

8Kyaingtong 3 84,000 70,000 87,250 241,2509NyaungShwe 3 88,885 66,500 24,000 179,385

10Hsipaw 5 10,500 5,000 100,100 115,600

11Kawthmu 11 250,000 130,000 190,550 570,55012Htilin 14 252,000 172,000 370,000 794,000

13YaeOo 2 0 0 101,799 101,79914Myeik 5 122,500 160,000 185,000 467,50015Ngaputaw 17 62,000 0 388,805 450,805

Total 122 2,317,885 1,829,500 3,341,069 7,488,454

Challenges

• Identification of poor (pre assessment)• Identification of poor (post assessment-

- easy for 25 and 50 bedded hospital, - difficult for 100 & 200 bedded hospitals

-management by OB Gyn• Poor but need elective LSCS• Poor in non emergency???• Sustainability

Thank You