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Effect of voucher programs on utilization, 
out of pocket expenditure and Quality of 
Postnatal Care: A 
multi-Country com...
Demand and supply side 
•Increasing ACCESS and UTILIZATION of selected maternal and 
reproductive health services as well ...
THE EVALUATION 
QUASI EXPERIMENTAL: PRE AND POST-INTERVENTION 
STUDIES WITH COMPARISONS 
 Baseline Studies: 2010-2012 
 ...
UTILIZATION OUTCOMES ANALYZED 
DELIVERY CARE 
Delivery at Facility 
Delivery at Public Facility 
Delivery by Medically ...
Delivery at Facility 
Cambodia 
Bangladesh 
Kenya Tanzania 
Uganda 
Crude DID=7.2** 
Adjusted DID=8.2** 
Crude DID=11.0***...
DELIVERY CARE 
 Greater increase in health facility delivery in voucher 
than in comparison sites in Bangladesh and Cambo...
Out of pocket analysis 
DIFFERENCE-IN-DIFFERENCE ANALYSIS ON 
PROPORTION PAYING FOR SELECTED MH 
SERVICS: 
Voucher areas v...
OOP : Proportion of Paying ANC 
Cost 
Cambodia 
Bangladesh 
Kenya Tanzania 
Uganda 
Crude DID= --28.0** 
Adjusted DID= --2...
OOP : Proportion of Paying 
Facility Delivery Cost 
Cambodia 
Bangladesh 
Kenya Tanzania 
Uganda 
Crude DID= -- 33.0 
** 
...
OUT-OF-POCKET PAYMENTS 
 Greater reduction in proportions of individuals paying 
out-of-pocket for delivery in a health f...
OUT-OF-POCKET PAYMENTS 
 Greater reduction in amount paid for delivery in a 
health facility (public or private) in vouch...
Quality of care analysis 
• Data collected between 2010 and 2014 across 
countries through observation of client provider ...
Process attributes of PNC examined 
Process 
attributes 
Elements assessed 
History taking (0-7) Date of delivery, if resu...
Process attributes of PNC examined 
Process 
attributes 
Elements assessed 
STI assessment and 
management (0- 
10) 
STI w...
Overall PNC process scores: Bangladesh & Cambodia 
% of functions 
Intervention Comparison DID 
performed 
Bangladesh Base...
Overall PNC process scores: Kenya & Tanzania 
% of functions 
performed 
Intervention Comparison DID 
Kenya Baseline 
n=70...
In summary cross country comparisons indicate: 
• That overall percentage scores for QOC for PNC were relatively low acros...
Implications for voucher programs 
• The program may have contributed to relatively stable quality 
of PNC In Kenya and Ta...
Ideas. Evidence. Impact. 
The Population Council conducts 
research and delivers solutions that 
improve lives around the ...
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Effect of Voucher Programs on Utilization, Out-of-Pocket Expenditure and Quality of Postnatal Care: A Multi-Country Comparison

A presentation by Timothy Abuya, delivered at the RBF Health Seminar, The Role of Vouchers in Serving Disadvantaged Populations and Improving Quality of Care.

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Effect of Voucher Programs on Utilization, Out-of-Pocket Expenditure and Quality of Postnatal Care: A Multi-Country Comparison

  1. 1. Effect of voucher programs on utilization, out of pocket expenditure and Quality of Postnatal Care: A multi-Country comparison Timothy Abuya, Ph.D The Role of Vouchers in Serving Disadvantaged Populations and Improving Quality of Care November 6th 2014 World Bank, Washington, DC
  2. 2. Demand and supply side •Increasing ACCESS and UTILIZATION of selected maternal and reproductive health services as well as to safe abortion services and family planning.  Improving quality of maternal services (PNC)  Reducing OUT OF POCKET EXPENDITURES on maternal and reproductive health services •Evaluate the impact of the program on improving reproductive health behaviors and status as well as reducing inequities at population level
  3. 3. THE EVALUATION QUASI EXPERIMENTAL: PRE AND POST-INTERVENTION STUDIES WITH COMPARISONS  Baseline Studies: 2010-2012  Endline Studies: 2013-2014 Identical Cross-sectional Population-based Household Surveys Study sites selected from Voucher areas and equal number of Comparison areas VOUCHER SAMPLE : Catchment areas of Contracted Health Centers Comparison SAMPLE: Catchment areas of Non-Contracted Health Centers HH Surveys fielded in HH’s within a 5km radius of Health Center MATCHED DESIGN: Control HCs selected and matched using propensity score: based on facility characteristics; services, staffing, average distance to referral hospital etc.
  4. 4. UTILIZATION OUTCOMES ANALYZED DELIVERY CARE Delivery at Facility Delivery at Public Facility Delivery by Medically Trained Provider Some contextual factor-related variations exist in measurement and operationalization in the 5 countries
  5. 5. Delivery at Facility Cambodia Bangladesh Kenya Tanzania Uganda Crude DID=7.2** Adjusted DID=8.2** Crude DID=11.0*** Adjusted DID=11.8*** Crude DID=8.0 Adjusted DID=5.9 Crude DID=7.0 Adjusted DID=8.9 Crude DID=0.8 Adjusted DID= 0.7
  6. 6. DELIVERY CARE  Greater increase in health facility delivery in voucher than in comparison sites in Bangladesh and Cambodia. African country DID’s large (except for Tanzania) but not significant  Greater increase in private health facility delivery in voucher than in comparison sites in Kenya and Uganda.  Greater increase in public health facility delivery in voucher than in comparison sites in Tanzania, Bangladesh and Cambodia.
  7. 7. Out of pocket analysis DIFFERENCE-IN-DIFFERENCE ANALYSIS ON PROPORTION PAYING FOR SELECTED MH SERVICS: Voucher areas vs. Non Voucher areas Proportion paying for: Any ANC Visit Delivery at a Facility PNC Visit Before and After Intervention comparison of out-of-pocket expenditures in all 5 countries for ANC, Delivery and PNC
  8. 8. OOP : Proportion of Paying ANC Cost Cambodia Bangladesh Kenya Tanzania Uganda Crude DID= --28.0** Adjusted DID= --27.0** Crude DID= --1.1 Adjusted DID= 1.1 Crude DID= --12.2*** Adjusted DID= -- 12.3***
  9. 9. OOP : Proportion of Paying Facility Delivery Cost Cambodia Bangladesh Kenya Tanzania Uganda Crude DID= -- 33.0 ** Adjusted DID= -- 35.0 ** Crude DID= -- 5.5 Adjusted DID= -- 4.8
  10. 10. OUT-OF-POCKET PAYMENTS  Greater reduction in proportions of individuals paying out-of-pocket for delivery in a health facility (public or private) in voucher than in comparison sites in Kenya and Tanzania but not in Uganda.  Greater reduction in proportion of individuals paying out-of-pocket for delivery in a private health facility in voucher than in comparison sites in Uganda  Greater reduction in proportion of individuals paying out-of-pocket for antenatal and postnatal care services in a health facility (public or private) in voucher than in comparison sites in Kenya.
  11. 11. OUT-OF-POCKET PAYMENTS  Greater reduction in amount paid for delivery in a health facility (public or private) in voucher than in comparison sites in Kenya and Tanzania but not in Uganda.  Greater reductions in amount paid for delivery in a private health facility in voucher than in comparison sites in Uganda.  Reductions in amount paid for antenatal care services in a health facility in voucher sites but increases in the same indicator in comparison sites in Kenya and Tanzania.  Note: Out-of-pocket payments are community averages; voucher clients on average paid nothing. Measured ITT.
  12. 12. Quality of care analysis • Data collected between 2010 and 2014 across countries through observation of client provider interactions during PNC service provision • Composite quality scores generated for various process elements • Regression models used to estimate DID between the two groups before and after implementation
  13. 13. Process attributes of PNC examined Process attributes Elements assessed History taking (0-7) Date of delivery, if resumed menses, about HIV status, about medication currently taken, place of delivery, mode of delivery, if currently breast feeding Physical examination (0-7) Took client's temperature, take client blood pressure, check for pallor (anemia), examine breasts and nipples, palpate the client’s abdomen for uterine involution, checked perineum and discharge / lochia, checked extent of Per vaginal bleeding Danger signs advice (0-3) Excessive vaginal bleeding, fever with or without chills, broken scars(Perineum/Caesarean) Fertility advice (0-4) Discuss return to fertility, discuss healthy timing and spacing of pregnancies /family planning, discuss the health benefits for mother and baby when birth spacing resume sexual activity, FP methods discussed (0-11) Combined pill, progestin only pill, emergency contraceptives, injectable, IUCD, implants, male/female condoms, male and female sterilization, fertility based methods
  14. 14. Process attributes of PNC examined Process attributes Elements assessed STI assessment and management (0- 10) STI with the client, HIV/AIDS with the client, STI and/or HIV risk factors with the client, Multiple partners, STIs increase risk of HIV, unprotected sexual intercourse, not knowing partner's status, Give information on symptoms of an STI, screen for STI, advise to seek medical treatment if they notice any symptoms of an STI, Infant feeding advice (0-3) discussed infant feeding, encourage discussing how mother was managing with breastfeeding, Re-emphasize exclusive feeding (either breast or replacement) Infant examination (0-4) Examine baby(undressed), check temperature, check baby's respirations, baby weighing Infant danger signs Discussed (0-4) Feeding difficulties - not sucking or sucking poorly, breathing difficulties, body feels hot or too cold, jaundice Rapport (0-8) Greets client, used clients name, introduces herself, tells client what will be done, Encourages client to ask question, ensured privacy, assures about confidentiality, Record all pertinent information on the client’s record/postnatal/FP card
  15. 15. Overall PNC process scores: Bangladesh & Cambodia % of functions Intervention Comparison DID performed Bangladesh Baseline n=44 Endline n=124 Baseline n=33 Endline n=115 Crude (95% CI) n=316 Maternal care (0-22) 15.0 15.0 21.0 22.0 -1.0 (-76.0,76.0) Infant care (0-11) 26.0 37.0 32.0 40.0 3.0(-32.0,29.6) Interpersonal skills (0-5) 63.0 62.0 62.0 61.0 0.0 (-16.4, 16.3) Overall quality score (0-38) 24.0 27.0 30.0 32.0 1.0 (-76.0, 76.0) Cambodia n=114 n=196 n=107 n=222 Adjusted (95% CI) n=634 Maternal care (0-22) 21.0 21.0 18.0 18.0 -3.0 (-10.2, 4.5) Infant care (0-11) 42.0 34.0 33.0 31.0 -7.0 (-20.0, 5.0) Interpersonal skills (0-5) 47.0 48.0 41.0 41.0 -1.0 (-18.3, 15.7) Overall quality score (0-38) 30.0 28.0 25.0 24.0 -4.0 (-12.6, 4.1)
  16. 16. Overall PNC process scores: Kenya & Tanzania % of functions performed Intervention Comparison DID Kenya Baseline n=704 Endline n=428 Baseline n=230 Endline n=141 Adjusted (95% CI) n=1476 Maternal care (0-42) 14.4 14.0 17.8 10.1 5.6*(-0.9,12.0) Infant care (0-11) 28.5 30.0 33.0 28.4 4.5 (-7.5, 16.5) Interpersonal skills (0-8) 52.4 48.8 55.4 47.5 1.6 (-9.2, 12.5) Overall quality scores (0-61) 22.5 22.2 26.1 19.3 4.8 (-2.6, 12.3) Tanzania n=103 n=117 n=94 n=94 n=387 Maternal care (0-22) 18.0 17.0 26.0 15.0 18.0*** [7.0, 30.0] Infant care (0-11) 72.0 51.0 68.0 48 .0 19.0 [-11.0, 48.0] Interpersonal skills (0-5) 71.0 69.0 75 .0 72.0 24.0** [3.0, 46.0] Overall quality scores (0-38) 54 .0 46.0 57.0 45.0 20.0** [2.0, 39.0]
  17. 17. In summary cross country comparisons indicate: • That overall percentage scores for QOC for PNC were relatively low across countries – Bangladesh: between 24-32% of the process elements were performed during PNC service. No changes in maternal care in both groups – Cambodia: between 24-30% of the PNC process elements were performed. There were variations individual aspects of PNC care – Kenya: 19-26% of the PNC process elements were performed on average. No changes in the individual aspects of care in the intervention facilities for both the mother and baby with a one percentage point increase on infant care. In the comparison facilities, there were reductions in all the aspects of care examined – Tanzania: 45-57% of the PNC process elements were performed on average with reductions in all aspects of PNC care for both the mother and the baby in both intervention and comparison facilities.
  18. 18. Implications for voucher programs • The program may have contributed to relatively stable quality of PNC In Kenya and Tanzania, compared to a decrease in comparison facilities • In Cambodia and Bangladesh, quality of PNC in intervention sites and control facilities remained largely unchanged • Interventions aimed at increasing demand without targeted focus on quality improvement through technical updates for providers may compromise quality • Program must deliberately endeavor to link funds generated from the demand and supply side initiatives to quality improvement . This should be supported with enabling policy environment that empowers facilities to use the funds to improve quality of services
  19. 19. Ideas. Evidence. Impact. The Population Council conducts research and delivers solutions that improve lives around the world. Big ideas supported by evidence: It ’s our model for global change.

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