Authors: Ubaidur Rob, Md. Moshiur Rahman, Benjamin Bellows

Journal: BMC Public Health 11(1): 257-257

Publication date: 2011

Abstract:

Background: Cost of delivering reproductive health services to low-income populations will always require total or partial subsidization by the government and/or development partners. Broadly termed “Demand-Side Financing” or “Output-Based Aid”, includes a range of interventions that channel government or donor subsidies to the service user rather than the service provider. Initial findings from the few assessments of reproductive health voucher-and-accreditation programs suggest that, if implemented well, these programs have great potential for achieving the policy objectives of increasing access and use, reducing inequities and enhancing program efficiency and service quality. At this point in time, however, there is a paucity of evidence describing how the various voucher programs function in different settings, for various reproductive health services.

Methods: Population Council-Nairobi, funded by the Bill and Melinda Gates Foundation, intends to address the lack of evidence around the pros and cons of ‘voucher and accreditation’ approaches to improving the reproductive health of low income women in five developing countries. In Bangladesh, the activities will be conducted in 11 accredited health facilities where Demand Side Financing program is being implemented and compared with populations drawn from areas served by similar non-accredited facilities. Facility inventories, client exit interviews and service provider interviews will be used to collect comparable data across each facility for assessing readiness and quality of care. In-depth interviews with key stakeholders will be conducted to gain a deeper understanding about the program. A population-based survey will also be carried out in two types of locations: areas where vouchers are distributed and similar locations where vouchers are not distributed.

Discussion: This is a quasi-experimental study which will investigate the impact of the voucher approach on improving maternal health behaviors and status and reducing inequities at the population level. We expect a significant increase in the utilization of maternal health care services by the accredited health facilities in the experimental areas compared to the control areas as a direct result of the interventions. If the voucher scheme in Bangladesh is found effective, it may help other countries to adopt this approach for improving utilization of maternity care services for reducing maternal mortality.

Offsite link: http://www.biomedcentral.com/content/pdf/1471-2458-11-257.pdf

Title: The use of vouchers for reproductive health services in developing countries: Systematic review

Authors: Nicole M. Bellows, Benjamin Bellows, Charlotte Warren

Journal: Tropical Medicine and International Health 16(1): 84-96

Publication date: 2011

Abstract:

Authors: Ubaidur Rob, Md. Moshiur Rahman, Benjamin Bellows

Journal: International Quarterly of Community Health Education 30(4): 293-309

Abstract: The maternal mortality ratio (322) is comparatively high in Bangladesh. The utilization of maternity care provided by trained professionals during and after delivery is alarmingly low, primarily due to lack of knowledge and money. The overall objective of this operations research project was to test the feasibility and effectiveness of introducing financial support (voucher scheme) for poor rural women to improve utilization of antenatal care (ANC), delivery and postnatal check-up (PNC) from trained service providers. A pretest-posttest design was utilized. A total of 436 women were interviewed before and 414 after the intervention to evaluate the impact of interventions. In-depth interviews were conducted with users and non-users of vouchers. Findings show that institutional deliveries have increased from 2% to 18%. Utilization of ANC from trained providers has increased from 42% to 89%. Similarly, utilization of PNC from trained providers has increased from 10% to 60%.

Offsite link: http://baywood.metapress.com/link.asp?id=n4437w2h677451g7

This report is intended for two audiences: (1) those involved in resource allocation related to current or new voucher programs; and (2) those operationally involved in the design, development, or improvement of voucher programs. It assumes a basic working knowledge of the function and purpose of voucher programs.

Since the 1970s concentration curves have increasingly been used to visually examine inequality in health outcomes and health service utilization (Kakwani, Wagstaff and van Doorslaer 1997). They provide a snapshot of how, in this case, utilization of family and maternity services varies across a distribution of individuals who are ranked from poorest to richest. The greater the distance between the concentration curve and the line of equality (the diagonal line that runs through the graph), the more concentrated the number of facility-based deliveries or use of LAPMs (Long-Acting and Permanent Method of family planning) among the richer individuals.

These concentration curves below are calculated from 2010 baseline survey of the Population Council’s evaluation of the Government of Kenya voucher program, four years after the voucher program was introduced in 2006. The main objective behind vouchers is to target services to those who are poor and equalize access to the healthcare system. Thus, we would expect that people in areas exposed to the OBA (Output-Based Aid) program would have a more equitable distribution or even a more ‘pro-poor’ (graphically this would translate to above or at the line of equality), distribution of health service use relative to the non-OBA sites.

Figure 1: The two concentration curves here show that the degree of inequality in OBA areas is lower than non-OBA areas for both facility-based deliveries and use of LAPMs (Long-Acting and Permanent Method of family planning).

In Figure 1, the CC lies below the line of equality in the OBA and non-OBA areas for use of facility-based deliveries. On the other hand, we notice that the concentration curves for LAPM use  are on opposite sides of the line of equality for OBA and non-OBA sites, and that for OBA sites, LAPM use is ‘pro-poor’ and lies above the line of equality.  In OBA sites, more poor women are using long term FP methods than non-poor women while the opposite is true for the non-OBA sites. Concentration curves provide a visual sense of the distribution of inequality; these graphs show us that the degree of health service utilization in OBA sites seems to be more equitable than in non-OBA sites.

However, in order to make a better conclusion as to whether these differences are truly significant, a numerical measure of health inequality can be used. A related measure, the concentration index (CI), quantifies the amount of inequality in a health variable (Kakwani, Wagstaff and van Doorslaer 1997).  It’s defined as twice the area between the concentration curve and the line of equality. CIs range between -1 and 1 and if there is no inequality, the index is equal to 0 (it may help to think of this as a correlation coefficient).

To take this a step further, the concentration index (CI) is positive when the concentration curve lies below the line of equality (e.g. indicating that poor have lower healthcare use or worse health outcomes).

Figure 2: Comparing concentration indices between OBA and non-OBA sites.

Figure 2 quantifies the information that we saw in Figure 1– that in 2010, LAPM use in the OBA sites is concentrated among the poorer populations relative to the non-OBA sites (hence the negative CI value). Facility-based deliveries seem to also be more equitably distributed in the OBA-sites relative to the non-OBA sites; however, both sites show ‘pro-rich’ utilization of this service.

The concentration index for the inequality of distribution in facility-based deliveries since the inception of the program in mid-2006, was 0.24 in the OBA sites and 0.13 in the non-OBA sites.  LAPM use was at -0.07 in the OBA sites and 0.03 in the non-OBA sites. These differences, however, were found to be statistically non-significant.

Finally, in order to provide us with a sense of whether this program has been equity enhancing, we will compare these curves to those generated from the endline surveys (collected August 2012), to observe whether the distribution of health utilization has changed over two years in voucher-exposed and non-exposed sites. For more information on concentration curves, indices, and equity analysis in health, please refer to the World Bank guidance document on Analyzing Health Equity Using Household Survey Data.

REFERENCES

1. Kakwani, N. C., A. Wagstaff, and E. van Doorslaer. 1997. “Socioeconomic Inequalities in Health: Measurement, Computation and Statistical Inference.” Journal of Econometrics 77(1): 87–104.

2. Wagstaff, A., and N. Watanabe. 2003. “What Difference Does the Choice of SES Make in Health Inequality Measurement?” Health Economics 12(10): 885–90.

(Image credit: All graphs produced by Karampreet K. Sachathep, © 2012)

A flagship course at the World Bank Institute in Washington, DC to be held in December will spend one day  of the two-week program focused on results-based financing (RBF). The course is targeting high-level policymakers from various countries, including Kenya. During this RBF module, Kadi will be presented in the context of a discussion about voucher schemes.

Agenda:

• Introduction by Joe Naimoli, USAID – Dr. Naimoli leads the Performance-Based Incentives Interest Group at USAID
• Presentation on reproductive health vouchers by Charlotte Warren, Population Council
• Presentation of Kadi
• Discussion facilitated by Maggie Farrell, USAID

Date: 29 November 2012

Time: 16:00

Healthcare fraud and error amount to 5-6% of global healthcare expenditure (US$236 billion) every year. US$236 billion could ensure safe water for the entire world, control malaria in Africa, provide vaccines for 23 million children, and quadruple the budgets of the WHO and UNICEF, with US$144 billion to spare (European Healthcare Fraud & Corruption Network). Because health systems in low-income countries generally lack systematic tracking and reporting mechanisms, fraud and error in low-income countries tend to be discussed relative to specific initiatives or projects. A recent example is the debate over the results of Global Fund audits.

Fraud and error are key issues for voucher programs, too, but these output-based aid programs lend themselves to better detection and management of fraud and error. According to “Defining Effective Voucher Management Information Systems” – an upcoming report to be published by the RH Vouchers project based on evaluation of voucher management information systems (MIS) in multiple countries – the potential for fraud and error within voucher programs could be more systematically addressed. In addition to what voucher programs are already doing, we explore what more can be done.

Current measures

All major voucher programs have anti-fraud and error control measures in place, using voucher design, claims vetting, and spot-checks of reimbursement request patterns. Because these efforts are implemented differently across programs, the ability to make useful cross-country performance comparisons is limited. While all voucher programs – like other large scale initiatives – have had to address accounting errors and respond to potential fraud, reporting can be improved and prevention efforts can be strengthened. Under current practices, the extent of fraud/error in the system can be estimated; however, more systematic methods could improve both the precision in those estimates and response times.

While all voucher programs have reported fraud, reports are largely anecdotal and claims are not always verified. As a result, the extent of the fraud/error problem can only be estimated.

In “Defining Effective Voucher Management Information Systems,” report authors Mahad Ibrahim, Ben Bellows, and Jaspal Sandhu recommend implementation of fraud and error detection mechanisms in relevant software modules and at multiple levels of deterrence (voucher, patient, facility, distributor). They recommend that claims are verified at these various levels as well.

Fraud and error are not unique to health systems in low- and middle-income countries, nor are fee-for-service programs exempt from fraud. In 2010, Medicare, the US national social health insurance program for the elderly and disabled spent US$528 billion – three times the annual budget of the UK’s National Health Service. In serving 48 million people, Medicare rejected 3.82% of claims. That same year, the “improper payment rate” for Medicare’s Fee-for-Service was 8.6%, representing $28.8 billion in spending of a total $336 billion in Medicare Fee-for-Service program.

Prevention & detection

In their 2010 systematic review of reproductive health vouchers in developing countries, Bellows, Bellows, and Warren note that prevention and detection systems are built directly into voucher programs. Prevention measures include the use of logos or barcodes to authenticate individual vouchers. Systematically verifying service delivery (e.g. unannounced facility visits or following up at home with sampled patients to confirm they received services) can also deter fraud since the awareness of enforcement systems is often enough to prevent people from committing fraudulent acts.

Bellows and colleagues also recommend detection systems, such as monitoring voucher sales and services for unusual patterns, such as spikes in distribution. As noted in “Defining Effective Voucher Management Information Systems,” voucher information systems that capably track vouchers, clients, distributors, and providers should additionally implement inexpensive, automated algorithms to identify errors and abnormal trends. Anna Gorter and Corinne Grainger in the Quick Guide to Developing Voucher Programmes (2011) as well as the World Bank’s 2005 Guide to Competitive Voucher Programs outline prevention and detection measures for program design, as well as tips for program managers. For example, Gorter and Grainger present recommendations for: prosecution of offenders, recovery of proceeds from fraudulent activity, staff training, and appropriate contracting measures to hold organizations accountable for fraudulent activity.

Information systems

In addition to the measures employed by the large voucher programs, there is an opportunity to leverage information systems to identify and manage both fraud and error. The current voucher claims processing software systems in the five countries reviewed by the “Defining Effective Voucher Management Information Systems” report – Bangladesh, Cambodia, Kenya, Tanzania, and Uganda – can build strong detection algorithms to augment existing anti-fraud and error-control measures. Certain limitations of the underlying systems will first have to be addressed, but there is significant potential for such an approach as voucher programs scale.

Voucher programs could also share information across sites, and use this information to both prevent fraud and detect error.  US public and private insurance programs, such as Medicare, Medicaid, and the Blue Cross and Blue Shield Association, are now using software for detecting anomalous patterns in shared claims data, and closely examining claims to see if multiple agencies are billed for the same patient services. A “trusted third party” often leads data analyses and pass on questionable claims for further investigation.

Although software systems offer a high-tech, automated solution to fraud and error detection problems, they are not sufficient. Most importantly, managers, government regulators, donors and researchers need to understand the extent and types of fraud and error that exist, especially before investing significant resources on a system that may provide little value in addressing fraud and error. Furthermore, efforts should not outweigh the price of fraud and error, since enterprise-level software systems typically cost significant time, money, and human resources.

Well-built information management systems should be combined with simpler measures, such as voucher design, spot-checks, and making regulation highly visible. Neither prevention strategies nor analytic methods alone are enough. The combination of prevention, detection, and enforcement measures will effectively minimize fraud and error, and improve the efficiency of resources brought to bear on pressing health needs.