Effect of voucher programs on utilization, out of pocket expenditure

and Quality of Postnatal Care: A multi-Country comparison

Timothy Abuya, Ph.DThe Role of Vouchers in Serving Disadvantaged Populations and Improving Quality of Care

November 6th 2014World Bank, Washington, DC

Demand and supply side

•Increasing ACCESS and UTILIZATION of selected maternal and reproductive health services as well as to safe abortion services and family planning.

Improving quality of maternal services (PNC)

Reducing OUT OF POCKET EXPENDITURES on maternal and reproductive health services

•Evaluate the impact of the program on improving reproductive health behaviors and status as well as reducing inequities at population level

THE EVALUATIONQUASI EXPERIMENTAL: PRE AND POST-INTERVENTION STUDIES WITH COMPARISONS

Baseline Studies: 2010-2012 Endline Studies: 2013-2014

Identical Cross-sectional Population-based Household Surveys

Study sites selected from Voucher areas and equal number of Comparison areas

VOUCHER SAMPLE : Catchment areas of Contracted Health Centers

Comparison SAMPLE: Catchment areas of Non-Contracted Health Centers

HH Surveys fielded in HH’s within a 5km radius of Health Center

MATCHED DESIGN: Control HCs selected and matched using propensity score: based on facility characteristics; services, staffing, average distance to referral hospital etc.

UTILIZATION OUTCOMES ANALYZED

DELIVERY CAREDelivery at FacilityDelivery at Public FacilityDelivery by Medically Trained Provider

Some contextual factor-related variations exist in measurement and operationalization in the 5 countries

Delivery at Facility

Cambodia

Tanzania Kenya

Bangladesh

Uganda

Crude DID=7.2**Adjusted DID=8.2**

Crude DID=11.0***Adjusted DID=11.8***

Crude DID=8.0Adjusted DID=5.9

Crude DID=7.0Adjusted DID=8.9

Crude DID=0.8Adjusted DID= 0.7

DELIVERY CARE

Greater increase in health facility delivery in voucher than in comparison sites in Bangladesh and Cambodia. African country DID’s large (except for Tanzania) but not significant

Greater increase in private health facility delivery in voucher than in comparison sites in Kenya and Uganda.

Greater increase in public health facility delivery in voucher than in comparison sites in Tanzania, Bangladesh and Cambodia.

Out of pocket analysis DIFFERENCE-IN-DIFFERENCE ANALYSIS ON PROPORTION PAYING FOR SELECTED MH SERVICS: Voucher areas vs. Non Voucher areas

Proportion paying for:Any ANC VisitDelivery at a Facility PNC Visit

Before and After Intervention comparison of out-of-pocket expenditures in all 5 countries for ANC, Delivery and PNC

OOP : Proportion of Paying ANC Cost

Cambodia

Tanzania Kenya

Bangladesh

Uganda

Crude DID= --28.0**Adjusted DID= --27.0**

Crude DID= --1.1Adjusted DID= 1.1

Crude DID= --12.2***Adjusted DID= -- 12.3***

OOP : Proportion of Paying Facility Delivery Cost

Cambodia

Tanzania Kenya

Bangladesh

Uganda

Crude DID= -- 33.0 **Adjusted DID= -- 35.0 **

Crude DID= -- 5.5Adjusted DID= -- 4.8

OUT-OF-POCKET PAYMENTS

Greater reduction in proportions of individuals paying out-of-pocket for delivery in a health facility (public or private) in voucher than in comparison sites in Kenya and Tanzania but not in Uganda.

Greater reduction in proportion of individuals paying out-of-pocket for delivery in a private health facility in voucher than in comparison sites in Uganda

Greater reduction in proportion of individuals paying out-of-pocket for antenatal and postnatal care services in a health facility (public or private) in voucher than in comparison sites in Kenya.

OUT-OF-POCKET PAYMENTS Greater reduction in amount paid for delivery

in a health facility (public or private) in voucher than in comparison sites in Kenya and Tanzania but not in Uganda.

Greater reductions in amount paid for delivery in a private health facility in voucher than in comparison sites in Uganda.

Reductions in amount paid for antenatal care services in a health facility in voucher sites but increases in the same indicator in comparison sites in Kenya and Tanzania.

Note: Out-of-pocket payments are community averages; voucher clients on average paid nothing. Measured ITT.

Quality of care analysis

• Data collected between 2010 and 2014 across countries through observation of client provider interactions during PNC service provision

• Composite quality scores generated for various process elements

• Regression models used to estimate DID between the two groups before and after implementation

Process attributes of PNC examined

Process attributes

Elements assessed

History taking (0-7)

Date of delivery, if resumed menses, about HIV status, about medication currently taken, place of delivery, mode of delivery, if currently breast feeding

Physical examination(0-7)

Took client's temperature, take client blood pressure, check for pallor (anemia), examine breasts and nipples, palpate the client’s abdomen for uterine involution, checked perineum and discharge / lochia, checked extent of Per vaginal bleeding

Danger signs advice (0-3)

Excessive vaginal bleeding, fever with or without chills, broken scars(Perineum/Caesarean)

Fertility advice (0-4)

Discuss return to fertility, discuss healthy timing and spacing of pregnancies /family planning, discuss the health benefits for mother and baby when birth spacing resume sexual activity,

FP methods discussed (0-11)

Combined pill, progestin only pill, emergency contraceptives, injectable, IUCD, implants, male/female condoms, male and female sterilization, fertility based methods

Process attributes of PNC examined

Process attributes

Elements assessed

STI assessment and management (0-10)

STI with the client, HIV/AIDS with the client, STI and/or HIV risk factors with the client, Multiple partners, STIs increase risk of HIV, unprotected sexual intercourse, not knowing partner's status, Give information on symptoms of an STI, screen for STI, advise to seek medical treatment if they notice any symptoms of an STI,

Infant feeding advice (0-3)

discussed infant feeding, encourage discussing how mother was managing with breastfeeding, Re-emphasize exclusive feeding (either breast or replacement)

Infant examination (0-4)

Examine baby(undressed), check temperature, check baby's respirations, baby weighing

Infant danger signs Discussed (0-4)

Feeding difficulties - not sucking or sucking poorly, breathing difficulties, body feels hot or too cold, jaundice

Rapport (0-8) Greets client, used clients name, introduces herself, tells client what will be done, Encourages client to ask question, ensured privacy, assures about confidentiality, Record all pertinent information on the client’s record/postnatal/FP card

Overall PNC process scores: Bangladesh & Cambodia% of functions performed

Intervention Comparison DID

Bangladesh

Baseline n=44

Endline

n=124

Baselinen=33

Endline

n=115

Crude (95% CI) n=316

Maternal care (0-22) 15.0 15.0 21.0 22.0 -1.0 (-76.0,76.0)

Infant care (0-11) 26.0 37.0 32.0 40.0 3.0(-32.0,29.6)Interpersonal skills (0-5)

63.0 62.0 62.0 61.0 0.0 (-16.4, 16.3)

Overall quality score (0-38)

24.0 27.0 30.0 32.01.0 (-76.0,

76.0)

Cambodia n=114 n=196 n=107 n=222Adjusted (95%

CI) n=634Maternal care (0-22) 21.0 21.0 18.0 18.0 -3.0 (-10.2, 4.5)

Infant care (0-11) 42.0 34.0 33.0 31.0 -7.0 (-20.0, 5.0)Interpersonal skills (0-5)

47.0 48.0 41.0 41.0 -1.0 (-18.3, 15.7)

Overall quality score (0-38)

30.0 28.0 25.0 24.0 -4.0 (-12.6, 4.1)

Overall PNC process scores: Kenya & Tanzania

% of functions performed

Intervention Comparison DID

Kenya

Baseline

n=704

Endline

n=428

Baselinen=230

Endline

n=141Adjusted (95%

CI) n=1476

Maternal care (0-42) 14.4 14.0 17.8 10.1 5.6*(-0.9,12.0)Infant care (0-11) 28.5 30.0 33.0 28.4 4.5 (-7.5, 16.5)Interpersonal skills (0-8) 52.4 48.8 55.4 47.5 1.6 (-9.2, 12.5)Overall quality scores (0-61)

22.5 22.2 26.1 19.3 4.8 (-2.6, 12.3)

Tanzania n=103 n=117 n=94 n=94 n=387

Maternal care (0-22)18.0

17.0

26.0

15.0

18.0*** [7.0, 30.0]

Infant care (0-11)72.0

51.0

68.0

48 .0

19.0 [-11.0, 48.0]

Interpersonal skills (0-5)71.0

69.0

75 .0

72.0

24.0** [3.0, 46.0]

Overall quality scores (0-38)

54 .0

46.0

57.0

45.0

20.0** [2.0, 39.0]

In summary cross country comparisons indicate:

• That overall percentage scores for QOC for PNC were relatively low across countries – Bangladesh: between 24-32% of the process elements were

performed during PNC service. No changes in maternal care in both groups

– Cambodia: between 24-30% of the PNC process elements were performed. There were variations individual aspects of PNC care

– Kenya: 19-26% of the PNC process elements were performed on average. No changes in the individual aspects of care in the intervention facilities for both the mother and baby with a one percentage point increase on infant care. In the comparison facilities, there were reductions in all the aspects of care examined

– Tanzania: 45-57% of the PNC process elements were performed on average with reductions in all aspects of PNC care for both the mother and the baby in both intervention and comparison facilities.

Implications for voucher programs

• The program may have contributed to relatively stable quality of PNC In Kenya and Tanzania, compared to a decrease in comparison facilities

• In Cambodia and Bangladesh, quality of PNC in intervention sites and control facilities remained largely unchanged

• Interventions aimed at increasing demand without targeted focus on quality improvement through technical updates for providers may compromise quality

• Program must deliberately endeavor to link funds generated from the demand and supply side initiatives to quality improvement . This should be supported with enabling policy environment that empowers facilities to use the funds to improve quality of services

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