A voucher scheme for adolescents of Managua An innovative programme to improve the uptake and quality of sexual health care Anna Gorter Zoyla Segura Patricia Gonzales Liesbeth Meuwissen ICAS and LSHTM Financed by DfID

Objectives Increase uptake of sexual health services by poor adolescentsIncrease uptake of sexual health services by poor adolescents Improve human and technical quality of these servicesImprove human and technical quality of these services Make these services accessible at low costMake these services accessible at low cost

How? Through distribution of vouchers to poor adolescentsThrough distribution of vouchers to poor adolescents By training staff of health servicesBy training staff of health services By monitoring quality,feedback and continuous supportBy monitoring quality,feedback and continuous support Through competitive tendering for the provision of servicesThrough competitive tendering for the provision of services

Supply Side Financing

Demand Side Financing

What is a voucher A document which can be exchanged for defined goods or services as a token of payment OR "Tied cash (as opposed to liquid cash)"

Some characteristics of vouchers Power of choice with the consumerPower of choice with the consumer Improves the quality of servicesImproves the quality of services Reduces costsReduces costs Uses existing infra-structureUses existing infra-structure Can target those most in needCan target those most in need Those in highest need, self-selectThose in highest need, self-select

Sex workers and their clients

The SW voucher programme in Managua Attracts sex workers, including young glue-sniffers, and their clientsAttracts sex workers, including young glue-sniffers, and their clients Those most in need, self-selectThose most in need, self-select Improved quality of servicesImproved quality of services Competition holds prices downCompetition holds prices down Reduces prevalence, incidence STIsReduces prevalence, incidence STIs

Nicaragua 4.8 million Managua 1 million

Adolescents of Managua Adolescents (12-19): Adolescents (12-19): Education:Education: –7% illiterate –39% no secondary schooling –Median of 6 years of schooling

Fertility adolescents Fertility: 139Fertility: 139 Highest of Central AmericaHighest of Central America Decrease of 25% from ’85 to ‘98Decrease of 25% from ’85 to ‘98 Adolescents 27% of birthsAdolescents 27% of births

Teenage pregnancies

Influence of education

Knowledge of FP by adolescents 97% knows at least one method97% knows at least one method Best known are the pill, injectables, IUD, condoms and sterilizationBest known are the pill, injectables, IUD, condoms and sterilization

Use of FP by female adolescents Of those sexually active:Of those sexually active: -21% made at least once use of FP -11% is actually using FP FP is obtained at:FP is obtained at: -62% in public sector -20% in NGO clinics -11% pharmacies - 7% private clinics

FP methods used The pill50%The pill50% IUD21%IUD21% Injectables16%Injectables16% Condoms 7%Condoms 7% Other methods 6%Other methods 6% Only 1/3 had no children before starting a method for the first time Only 11% of non-users had visited a service during last year to discuss FP

Health care provider reasons of non-use sexual health services Low human quality of services:Low human quality of services: - unfriendly, no confidentiality - long waiting times - no ability counseling adolescents Low technical quality, limited knowledge:Low technical quality, limited knowledge: - IEC counseling - FP methods - STIs

Adolescents reasons for non- use of sexual health services Physical barriers: cost and distancePhysical barriers: cost and distance Cultural barriersCultural barriers Unfamiliar with their own bodyUnfamiliar with their own body Not familiar with existing servicesNot familiar with existing services Poor perceived quality of carePoor perceived quality of care Risk of meeting family, friendsRisk of meeting family, friends

World Bank Policy Delayed demographic transmissionDelayed demographic transmission High to medium fertility; recent declines; population growth still high; poor reproductive healthHigh to medium fertility; recent declines; population growth still high; poor reproductive health Address demand for FP and RHAddress demand for FP and RH Ensure access to RHEnsure access to RH Target delivery of RH to the poorTarget delivery of RH to the poor

The project: methods used Baseline study among adolescentsBaseline study among adolescents Cost study of servicesCost study of services Assessment of qualityAssessment of quality Open invitation to servicesOpen invitation to services Contracting of servicesContracting of services Treatment protocols and trainingTreatment protocols and training Start of the programmeStart of the programme Monitoring of qualityMonitoring of quality

Quality control Exams with medical doctorsExams with medical doctors Use of mystery patientsUse of mystery patients Semi-structured interviews with voucher usersSemi-structured interviews with voucher users Focus group discussionsFocus group discussions Medical record reviewMedical record review

Results quality control Low technical quality of:Low technical quality of: - IEC and low knowledge of FP methods - low knowledge of STIs Low human quality:Low human quality: - doctors don’t know how to address young people - doctors don’t provide a choice between different FP methods - no confidentiality - many other complaints about waiting times, unfriendliness etc

Health services contracted 17 clinics (at start 4 clinics, goal 20)17 clinics (at start 4 clinics, goal 20) - 3 public clinics (municipality)- 3 public clinics (municipality) - 9 NGO clinics - 5 private clinics/doctors Clinics contract laboratory servicesClinics contract laboratory services Price per consultation:Price per consultation: - between 1.1 and 2.8 US$ - average 2.3 US$ FP methods, treatment and education material centrally procuredFP methods, treatment and education material centrally procured

Services offered First and follow-up consultationFirst and follow-up consultation IEC counselingIEC counseling Family planningFamily planning Pregnancy testingPregnancy testing First pregnancy control, laboratory tests and referralFirst pregnancy control, laboratory tests and referral STI services (syndromic treatment)STI services (syndromic treatment) Referral to specialist servicesReferral to specialist services

Treatment protocols and training Design of treatment protocol and manualsDesign of treatment protocol and manuals A clinical data collection form which also guides medical doctorsA clinical data collection form which also guides medical doctors Training of medical doctorsTraining of medical doctors After one month follow-up training for medical doctors, nurses and receptionistsAfter one month follow-up training for medical doctors, nurses and receptionists Emphasis on improving ability to council and on attitudes towards adolescentsEmphasis on improving ability to council and on attitudes towards adolescents

Distribution of the vouchers By the voucher agency ICAS (markets, house to house, streets, outside schools in poor barrios)By the voucher agency ICAS (markets, house to house, streets, outside schools in poor barrios) Through NGOs working with poor adolescentsThrough NGOs working with poor adolescents Adolescents organizations related to contracted clinicsAdolescents organizations related to contracted clinics Through clinics (voucher are given to pregnant adolescents for friends etc)Through clinics (voucher are given to pregnant adolescents for friends etc)

Distribution Distribution is continuously, each month date of validity is changedDistribution is continuously, each month date of validity is changed Vouchers valid for a period of 2-3 monthsVouchers valid for a period of 2-3 months DistributionDistribution - ICAS81 % - NGOs 6 % - Clinic related youth org.10 % - In clinics 3 %

Use of vouchers > 20,000 vouchers were distributed> 20,000 vouchers were distributed - 56% to girls - 44% to boys >2,000 vouchers were redeemed:11%>2,000 vouchers were redeemed:11% - girls 17 % (1,700) - boys 4 % ( 320)

Type of services asked for* girlsboys IEC22%42%IEC22%42% FP32%25%FP32%25% Pregnancy test 18% -Pregnancy test 18% - Prenatal control24% -Prenatal control24% - STIs33%32%STIs33%32% * more than one reason possible

Characteristics of users compared to overall adolescents population Education:Education: - girls about the same - boys a bit higher Users are poorerUsers are poorer Users start sexual activity much earlier:Users start sexual activity much earlier: - girls mean age 15 against % before age of 15 against 12%

Continuation characteristics Users are more often mother or father:Users are more often mother or father: - girls: 34% against 20% - boys: 22% against 4% Girls are more often pregnant Girls are more often pregnant - 24% against 4.5%

Prenatal control Of female users 24% were pregnantOf female users 24% were pregnant 75% had never had a prenatal control75% had never had a prenatal control Of these:Of these: - 28% in their first 3 months - 57% 3 to 6 months pregnant - 7.5% 6 to 8 months pregnant - 7.5% > 8 months pregnant

What we achieved Vouchers could be distributed to adolescents and were usedVouchers could be distributed to adolescents and were used Poorer and more needy adolescents made more use of their voucherPoorer and more needy adolescents made more use of their voucher Clinics participated enthusiasticallyClinics participated enthusiastically Medical doctors recognized inability of counseling adolescents and welcomed trainingMedical doctors recognized inability of counseling adolescents and welcomed training

continuation achievements Power of choice with consumerPower of choice with consumer Clinics offered services at prices well below their standard rates and even below the unit costs of equivalent services at MoH centersClinics offered services at prices well below their standard rates and even below the unit costs of equivalent services at MoH centers Central procurement of IEC material, medical supplies ensures efficiencyCentral procurement of IEC material, medical supplies ensures efficiency

What we hope to achieve To engender changes in the provision of services based on the requirements of the usersTo engender changes in the provision of services based on the requirements of the users Innovative approaches of services to attract adolescentsInnovative approaches of services to attract adolescents To improve human quality and technical quality of existing servicesTo improve human quality and technical quality of existing services

In resume an adolescent voucher scheme can: Give power of choice to adolescents, clinics with best quality are more usedGive power of choice to adolescents, clinics with best quality are more used Target those most in needTarget those most in need Those in highest need, self-select furtherThose in highest need, self-select further Can be distributed by third partiesCan be distributed by third parties Increase use of servicesIncrease use of services Use existing infra-structureUse existing infra-structure Be geographical independentBe geographical independent Improve human and technical quality of services contractedImprove human and technical quality of services contracted

In other words; a voucher schemes might offer Increased equity in access to health careIncreased equity in access to health care Greater choiceGreater choice Improved quality of servicesImproved quality of services Increased uptake of servicesIncreased uptake of services More effective and efficient targetingMore effective and efficient targeting Use of existing infra-structureUse of existing infra-structure Efficient and cheapEfficient and cheap