Voucher Scheme for Equity in Health Dr Nidhi Chaudhary Futures Group India
Challenges in Health System Low accessibility to health services High infant mortality rate Underutilization of services Low use of contraception Staff vacancies and lack of trained staff in public health system
Opportunities Enabling environment under National Rural Health Mission Increased emphasis on improving access to institutional delivery Market presence of viable private sector Quality services in private sector Private sector is preferred provider choice in rural areas as well
Voucher Scheme Demand side financing that helps to purchase outputs, while also offering beneficiaries a choice of provider.
Goal of the Voucher Scheme To reduce inequities in reproductive health care by enabling access to services, while empowering the BPL population to choose their own provider
Voucher Scheme Pilots Under the Innovations in Family Planning Services II (IFPS II) project being implemented in Uttar Pradesh and Uttarakhand, 3 pilots are being conducted. IFPS II is funded by USAID Futures is the technical assistance agency for IFPS II
Voucher Scheme 3 pilots Agra Kanpur Haridwar Area Rural Urban slums Rural Coverage 7 blocks 360 slums 2 blocks Providers Private Private Private Services Voucher Management Voucher Distribution ANC, Delivery, PNC, FP and RTI/STI ANC, Delivery, PNC, FP and RTI/STI ANC, Delivery, Neonatal complications, PNC and FP CMO, PMU NGOs CMO, DPMU ASHAs through NGOs CHVs through NGOs ASHAs through ANMs
Area of Coverage Implemented in two blocks of District Haridwar Imlikheda and Bahadrabad
Population Coverage 451,743 individuals in 199 villages Target Population Primary: BPL individuals (Especially, women and infants) Secondary: Men for FP services
Voucher Management System Voucher Management Agency Voucher Distribution Voucher Redemption ANM Private Nursing Homes Payment for Services Voucher Distribution ASHA Voucher Redemption BPL Families Voucher Distribution
RCH Services Provided ANC - 3 visits, ANC check up, TT injection, IFA tablets, nutrition advice, laboratory investigations. Deliveries - Normal and Caesarean Neonatal Complications - Respiratory Distress Syndrome, jaundice, hypothermia, other complications. PNC - 2 check ups, breast feeding and FP counseling Family Planning - Sterilization, IUCD, condoms and pills
Voucher Design & Communication Plan Holographic stickers and water mark used Eight digit code to identify district, block, and service Strategic communication plan Branding logo and tag line: Coupon Lao Sehat Pao Glow signs for nursing homes Leaflets, posters and flip books ASHA training on mobilising beneficiaries
Cost of Services ANC check up Normal delivery Caesarian delivery Respiratory Distressed Syndrome Neonatal complications PNC FP Services Rs 25 per visit Rs 1500/- inclusive of medicines, one day hospital stay and pediatrician visit Rs 5,000 inclusive of medicines, anesthetist charges, Cost of services are at least 35-50 percent less than prevailing market prices 5/6 days hospitalization, pediatrician visit Rs 1000 inclusive of medication, 2-7 days of hospitalisation, pediatrician visit Rs 500 inclusive of medication, hospitalisation, pediatrician visit Rs 25 per visit Rs 1,500 per sterilization and Rs 100 per IUCD
M&E and Quality Assurance Mechanisms Accreditation of health facilities Formation of Project Advisory Group to review and guide implementation MIS introduced at various levels Orientation and regular meetings with ASHA
M&E and Quality Assurance Mechanisms Monitoring visits by Chief Medical officer and District Programme Manager Medical Audit Client Satisfaction Survey Continuous Medical Education Training of health staff on contraceptive update, infection prevention and waste management
Progress to Date
Progress to Date Creation of a panel of 7 accredited health facilities for provision of select FP and RH services 48 ANMs and 472 ASHAs trained on Voucher scheme Distribution of vouchers among BPL families Regular performance and financial reporting and financial disbursement systems
Performance of Voucher Scheme Services 18 months target HARIDWAR Actual Achievement Percent Achieved ANC 2065 5387 260.9 Institutional Delivery PNC 1579 2077 131.5 565 1279 226.4
Performance of Voucher Scheme Services 18 months target HARIDWAR Actual Achievement Percent Achieved Respiratory Distress Syndrome 79 74 93.7 Phototherapy 32 52 162.5 Incubator 268 33 12.3 Neonatal Complications 95 108 113.7
Client Satisfaction Survey 100 Level of Satisfaction 90 80 70 74.2 72.3 79.6 81.5 60 50 40 30 20 10 0 24.1 20.2 17.5 14.8 5.6 3.7 2.9 Satisfied Some Extent Not Satisfied ANC Delivery PNC Family Planning 3.7
Client Satisfaction Survey Percent Distribution of Clients by ANC Diagnostics Blood pressure HB test 85.2 92.1 Urine examination Ultrasound 70.4 68.5 IFA tablets Blood group with RH factor Blood sugar 45.4 50.5 49.5 Urine microscopy 18.1 0 10 20 30 40 50 60 70 80 90 100 Percent
Client Satisfaction Survey Reasons for Not Availing All Services Staff behaviour Transport not available No time to go Family does not allow Got to know of voucher late Services are charged Better care at home Not necessary 1.3 2.3 4.7 0.4 5.1 11.9 18.5 55.6 0 10 20 30 40 50 60 Percent
Medical Audit Reasons for Caesarean Sections Indication for Caesarean No. of Cases Foetal complication 37 Obstetric Hemorrhage 29 Pre Eclampsia 12 Obstructed Labour 01 Malpresentation 4 Twins 2 Maternal Complication 7
Medical Audit Scoring for Diagnosis, Appropriateness of Management and Quality of care 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 2.54 2.29 3.33 3.5 3.04 1.77 2.63 2.47 2.26 2.92 3.19 2.92 3.1 3 2.74 2.4 1.86 1.54 3.21 3 2.78 Loomba Happy Preet Prem Sanjeevan Seema St Joseph Diagnosis Management Quality of care
Outputs Systems established for distribution of vouchers, monitoring, disbursement of finances, medical audit and feedback from clients Increased utilization of ANC, PNC, institutional delivery and neonatal health services amongst BPL families Good quality RCH services accessible to BPL families
Outputs More efficient use of resources of private providers due to increased volumes Scheme caters to complicated deliveries, thus reducing maternal and neonatal morbidity/mortality Scale up of voucher scheme
Thank You!