1. 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

2. Financing of Health in Pakistan
Source: National Health Accounts

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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)

15. 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

16. 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

17. Thank You