“Vouchers for Services and Supplies ” Christine Namayanja, Programme Director, Marie Stopes International Uganda 28 th May| Reproductive Health Supplies Coalition Meeting| Kampala Uganda Improving Access to Health Services for the Poor through Output Based Aid:

Purpose Highlight the impact of private sector in reaching out to get a market that otherwise would not take up the services. Describe how the OBA approach improves RH commodity security-ensures supplies are always available.

Output Based Aid (OBA) is a results based financing mechanism that ties the disbursement of subsidies to clearly specified outputs that directly support improved access to basic services. What is Output Based Aid

At the Heart of OBA 1.Contracting out of service provision to an already existing service provider (third party) 2.Bridging of the financing gap between what the target group are able to pay for basic health services and the required cost for providing services.

Contrast of a traditional input based approach to OBA approach Inputs (such as materials) Private finance Public finance Service recipient Service Provider Private financing mobilized by service providers Reimbursement for outputs delivered Traditional input-based approach O utput-based approach Service Provider Service recipient Inputs (such as materials) Source: Output-Based Aid Lessons Learned and best Practices

Uganda OBA Programme Overview The Uganda OBA Project finances the provision of quality healthcare for safe deliveries and STD management by −selling vouchers to clients at −highly subsidised prices and by −reimbursing the costs to the −accredited private service provider for the −actual services provided.

General mechanism of the OBA Programme Donor KfW / GPOBA MSIU Distributor (pharmacy, drug shop, CBD) Private Provider Voucher recipient $ Service $ $ report

Service Package Safe DeliverySTD Management Voucher benefits (services covered) Safe delivery: 4ANCs, Basic & EMOC, PNC STD Management Eligible recipientsPoor womenSexually active people, focus on poor and high risk Geographic area covered 20 districts6 districts Beneficiaries 60,000 deliveries35,000 cases

Voucher Distribution Safe DeliverySTD Management CoverageMainly rural basedSemi-rural based Eligibility criteriaUse of Poverty Grading Tool & home visits for qualification of poor mothers No specific qualification criteria-all sexually active Distribution systemUse of trained CBDsPharmacies & drug shops Voucher selling price$ 2$1

Management of Service Provision Mapping, selection and approval-participating clinics Defined service protocols and guidelines- Cost of services agreed Training & orientation of service providers in OBA and service package. Claims processing & management Reimbursement/payment of providers

Contract management −External periodic facility Quality Assessments for service quality, fraud detection, right targeting etc Quality services means:- good counseling and client care, constant availability of qualified personnel, adequate stocks of medicines, vaccines, consumables/medical supplies, equipment −Client M&E for right cost, good client care, fraud detection. Good client care:- in addition to professional treatment of clients, health providers should ensure that get all the required drugs and are not charged for supplies −Renewal or termination of contracts.

Key Lessons: Targeting New Populations Recipient strategy- targeted approach as opposed to a universal approach (difficult-to-reach groups, poor, high risk). Benefits Lowest wealth quintile in rural communities of south and western Uganda reached. Equitable distribution of resources as vouchers are distributed to disadvantaged and poor women Removing cost and quality barriers has improved uptake of services Client satisfaction leads positive health seeking behaviour-clients asking for other services Potential draw backs Vouchers aimed at disadvantaged groups may leak directly or indirectly to less disadvantaged Voucher recipients may lack reliable information to choose - vouchers can be stigmatizing Relies on availability of extra capacity-existence of providers

Key Lessons: Quality Improvements Increased engagement of private sector capital and expertise by encouraging the private sector to serve poor customers they would otherwise disregard. VSPs have hired skilled staff to provide services to voucher clients

Key Lessons: Quality Improvements Benefits Voucher Service Providers have made infrastructure improvements Improved & expanded facilities Increased stocks of drugs & ensured availability (no stock outs) Purchase of relevant equipment Purchase of cars or motorcycles for emergency transport Potential draw backs Access to finance- if cost of pre- financing the outputs would place undue burden to the provider. Security of funding- swift disbursement when outputs have been achieved

Key Lessons: Quality Improvements Benefits Increased accountability by shifting performance risk to service by paying them only after delivering “agreed” outputs –Record keeping has improved- monitoring for results made possible –Monitoring of distribution on behalf of the management agency by reporting and repulsing wrong clients. Produces the most tangible cost of delivering services. Potential draw backs Services may become fragmented Administration and monitoring system costs may be high