Demand Side Financing – Tools to Improve RH Access and Uptake Leadership in Reproductive Health and Sustainable Development – Linking Research with Policy 26th September 2013 Demand Side Financing – Tools to Improve RH Access and Uptake Dr. Adnan A. Khan Director Research and Development Solutions, Islamabad

Financing of Health in Pakistan Source: National Health Accounts 2007-8

Public Health Funding and Preventive Health 90%+ of all health funding goes to curative healthcare 50-60% of family planning is self paid 95% birthing services are self paid 3% of childhood immunization are in the private sector

Health ≠ Healthcare ≠ Access to Healthcare RAND Experiment (1970s) Oregon Medicaid Study (2000s) Providing individuals with health insurance affords them access to healthcare It does not improve useful health access It does not improve their health status

What does this mean? Information asymmetry Not all healthcare sought leads to health Preventive health makes a difference but is often neither sought nor provided Health promotion would require approaches to improve preventive care

What is DSF It’s a financial means to create demand for some services that are required (i.e. to improve health) but not being sought by people Places purchasing power in the hands of the consumers Incentivizes them to pursue certain services It differs from free (usually govt.) services in that financing focuses on certain services Examples: CCT, vouchers

Advantages and Issues Advantages Issues Can direct clients to particular services Poor clients may still incur high costs for services they feel necessary but are not covered Can actually promote health rather than just healthcare seeking Availability of services and quality of services Transparency Increase market competition among providers Advantages to health are indirect

Conditional Cash Transfers Payment to community members for availing certain services considered as public good such as immunization, school attendance Successfully used in Mexico, other Latin American and African countries

Vouchers: Bangladesh For maternal health/ birthing services Increased client satisfaction Increased ANC, facility deliveries, PNC, facility use and EmOC by the poor but not FP Decreased differences between poor and rich Rich still used govt. facilities more than the poor More modest successes than anticipated Limited success related to poor service quality and choice

Vouchers: Cambodia Vouchers for in 3 rural districts Increased facility deliveries 3 fold Increase occurred in voucher and self pay clients (slightly more for vouchers) More improvements seen among the poor

Vouchers: Pakistan Vouchers for FP in 73 districts – peri-urban 4+ methods of FP promoted via fixed facilities Poverty scoring Significant improvements among the poor CPR increased by >10% per annum

More pending evidence from Pakistan… Punjab Health Sector Reform Program (PHSRP) pilot of subsidy for RH: health cards in three districts of Pakistan Medication Hospitalization Microfinance CHARMS: round the clock EmONC services at selected health facilities in 7 flood affected districts of Punjab. TRDP: health insurance schemes (with Adamjee Insurance) worth Rs. 20,000 at an annual insurance cost of Rs. 230 Evidence of efficacy pending

Summing up DSF DSF changes health behaviors +/- provides health financing Probably work best for “one-time” services Help the poor by overcoming limitations in access and uptake of RH services – esp in rural locations with few providers Cost savings over the public sector –reduced healthcare cost and reduced necessity of permanent government employees May promote health and progress towards MDGs Experiments needed to cover costs of transport, opportunity costs Sustainability (immediate vs. recurring costs) Duration long enough to bring about behavioral change Limited value in absence of economic uplift

Challenges Dependency of recipients and misuse Targeting the poor Administrative costs/Quality control Systematic corruption Lack of suppliers - Limited application unless services are available Sustainability of demand side financing schemes Social determinants play a big role (have we thought about these)

Recommendations Target usage and access to services in remote locations and for marginalized populations, Stringent monitoring and oversight mechanisms (which in turn can be contracted out) What may be addressed with DSF can be: Skilled birth attendance or facility deliveries Ante- and postnatal care, family planning and post abortion services Nutrition (including micronutrients) of mothers and children

Recommendations Specially suited for locations where the public sector is perennially short staffed Develop a trust fund to fund DSF Innovations If successful, should become part of routine (non dev) budget Types of support can include Payments of services to be availed Monetary incentives to actually avail services Costs of transport

Thank You