A voucher scheme for A voucher scheme for adolescentsadolescents of Managua of Managua

An innovative programme to An innovative programme to improve the uptake and quality of improve the uptake and quality of

sexual health caresexual health care

Anna GorterAnna Gorter

Zoyla SeguraZoyla Segura

Patricia GonzalesPatricia Gonzales

Liesbeth MeuwissenLiesbeth Meuwissen

ICAS and LSHTMICAS and LSHTM

Financed by DfIDFinanced by DfID

ObjectivesObjectives• IIncrease ncrease uptake uptake of sexual health of sexual health

servicesservices by by poor poor adolescentsadolescents

• IImprove human and technical mprove human and technical quality of quality of thesethese services services

• Make these serMake these servicesvices accessible accessible at low costat low cost

How?How?• Through distribution of vouchers to Through distribution of vouchers to

poor adolescentspoor adolescents

• By training staff of health servicesBy training staff of health services

• By By monitoringmonitoring qualityquality,feedback and ,feedback and continuous support continuous support

• TThrough competitive tendering for hrough competitive tendering for the provision of servicethe provision of servicess

Supply Side FinancingSupply Side Financing Contract/Norms Exemption Mechanism and Standards Users

Funding Agency

Health Care Provider

Health Care Provider

Demand Side FinancingDemand Side Financing

Users

FundingAgency

Health CareProvider

Health CareProvider

Independent Purchaser

What is a voucherWhat is a voucherA document which can be exchanged A document which can be exchanged

for for defined defined goods orgoods or services as a services as a token of paymenttoken of payment

OROR  

"Tied cash"Tied cash(as opposed to liquid cash)"(as opposed to liquid cash)"

Some characteristics of Some characteristics of vouchersvouchers

• 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-select Those in highest need, self-select

Sex workers and their clientsSex workers and their clients

SEX WORKERSCLINICS

VOUCHER AGENCY

DONOR / GOVERNMENT

NGO's

VOUCHER

VOUCHER

VOUCHER

VOUCHER

VOUCHER

CLIENTS & PARTNERS

VOUCHER

VOUCHER

VOUCHER

The SW voucher The SW voucher programme in Managuaprogramme in Managua

• Attracts sex workers, including Attracts sex workers, including young glue-sniffers, and their clientsyoung glue-sniffers, and their clients

• Those most in need, self-select Those most in need, self-select

• Improved quality of servicesImproved quality of services

• Competition holds prices downCompetition holds prices down

• Reduces prevalence, incidence STIs Reduces prevalence, incidence STIs

Prevalence gonorrhoea female sex workersPrevalence gonorrhoea female sex workers

10%

7.9%

14.5%

8.4%

7.5%

– In all redeemers round I

– In all redeemers round VIII

– FSWs (4 or more times),first consultation

– FSWs (4 or more times),last consultation

– FSWs who used only once a voucher

0% 5% 10% 15%

Prevalence rate of gonorrhoea

FSWs of poorest sites had highest disease prevalence.....

FSWs of poorest sites had highest disease prevalence.....

Gonorrhoea Syphilis 0%

2%

4%

6%

8%

10%

12%

14%

16%Disease prevalence rate

Glue-sniffers Market Bars/Streets Red District

....and were also those who redeemed more vouchers

....and were also those who redeemed more vouchers

0%

8%

16%

24%

32%

40%

48%

56%

64%

72%

80%Redemption Rate of Vouchers

Glue-sniffers Market Bars/Streets Red District

NicaraguaNicaragua

4.8 million4.8 million

ManaguaManagua

1 million1 million

Adolescents of ManaguaAdolescents of Managua

• Adolescents (12-19): 187.000Adolescents (12-19): 187.000

• Education: Education:

–7% illiterate7% illiterate

–39% no secondary schooling39% no secondary schooling

–Median of 6 years of schoolingMedian of 6 years of schooling

Fertility adolescentsFertility adolescents• Fertility: 139Fertility: 139

• Highest of Highest of Central AmericaCentral America

• Decrease of 25% Decrease of 25% from ’85 to ‘98from ’85 to ‘98

• Adolescents Adolescents 27% of births27% of births 0

20406080

100120140160180200

'85 '93 '98

Fertility

Teenage pregnanciesTeenage pregnancies

0

5

10

15

20

25

30

35

40

45

50

15 16 17 18 19

Mother or Pregnant

Influence of educationInfluence of education

0

10

20

30

40

50

60

0 1-3 4-6 7-12 >12

Mother or Pregnant

Knowledge of FP by Knowledge of FP by adolescentsadolescents

• 97% knows at least one 97% knows at least one methodmethod

• Best known are the pill, Best known are the pill, injectables, IUD, condoms injectables, IUD, condoms and sterilization and sterilization

Use of FP by female Use of FP by female adolescentsadolescents

• Of those sexually active:Of those sexually active:-21% made at least once use of FP-21% made at least once use of FP-11% is actually using FP -11% is actually using FP

• FP is obtained at:FP is obtained at:-62% in public sector-62% in public sector-20% in NGO clinics-20% in NGO clinics-11% pharmacies-11% pharmacies- 7% private clinics - 7% private clinics

FP methods usedFP methods used• The pillThe pill 50%50%• IUDIUD 21%21%• InjectablesInjectables 16%16%• CondomsCondoms 7% 7%• Other methodsOther methods 6% 6%

Only 1/3 had no children before starting aOnly 1/3 had no children before starting amethod for the first timemethod for the first timeOnly 11% of non-users had visited aOnly 11% of non-users had visited aservice during last year to discuss FPservice during last year to discuss FP

Health care provider reasons of Health care provider reasons of

non-use sexual health servicesnon-use sexual health services • Low human quality of services:Low human quality of services:

- unfriendly, no confidentiality- unfriendly, no confidentiality- long waiting times- long waiting times- no ability counseling adolescents- no ability counseling adolescents

• Low technical quality, limited knowledge:Low technical quality, limited knowledge:- IEC counseling- IEC counseling- FP methods- FP methods- STIs- STIs

Adolescents reasons for non-Adolescents reasons for non-use of sexual health servicesuse 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 care Poor perceived quality of care

• Risk of meeting family, friendsRisk of meeting family, friends

World Bank PolicyWorld Bank Policy• Delayed demographic transmissionDelayed demographic transmission• High to medium fertility; recent High to medium fertility; recent

declines; population growth still declines; population growth still high; poor reproductive healthhigh; 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 poor Target delivery of RH to the poor

The project: methods usedThe 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

VOUCHER

ADOLESCENTS

CLINICS

VOUCHER AGENCY

DONOR / GOVERNMENT

NGOs

VOUCHER

VOUCHER

VOUCHER

VOUCHER

How the Voucher Scheme Works

Quality controlQuality control

• Exams with medical doctorsExams with medical doctors

• Use of mystery patientsUse of mystery patients

• Semi-structured interviews with Semi-structured interviews with voucher usersvoucher users

• Focus group discussionsFocus group discussions

• Medical record reviewMedical record review

Results quality controlResults quality control• Low technical quality of: Low technical quality of:

- IEC and low knowledge of FP methods- IEC and low knowledge of FP methods- low knowledge of STIs- low knowledge of STIs

• Low human quality:Low human quality: - doctors don’t know how to address young - doctors don’t know how to address young peoplepeople- doctors don’t provide a choice between different - doctors don’t provide a choice between different FP methodsFP methods- no confidentiality- no confidentiality- many other complaints about waiting times, - many other complaints about waiting times, unfriendliness etc unfriendliness etc

Health services contractedHealth 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- 9 NGO clinics- 5 private clinics/doctors- 5 private clinics/doctors

• Clinics contract laboratory services Clinics contract laboratory services • Price per consultation:Price per consultation:

- between 1.1 and 2.8 US$ - between 1.1 and 2.8 US$ - average 2.3 US$- average 2.3 US$

• FP methods, treatment and education material FP methods, treatment and education material centrally procuredcentrally procured

Services offeredServices offered• First and follow-up consultationFirst and follow-up consultation• IEC counselingIEC counseling• Family planningFamily planning• Pregnancy testingPregnancy testing• First pregnancy control, laboratory tests First pregnancy control, laboratory tests

and referraland referral• STI services (syndromic treatment)STI services (syndromic treatment)• Referral to specialist servicesReferral to specialist services

Treatment protocols Treatment protocols and trainingand training

• Design of treatment protocol and manualsDesign of treatment protocol and manuals• A clinical data collection form which also A clinical data collection form which also

guides medical doctorsguides medical doctors• Training of medical doctorsTraining of medical doctors• After one month follow-up training for After one month follow-up training for

medical doctors, nurses and receptionistsmedical doctors, nurses and receptionists• Emphasis on improving ability to council Emphasis on improving ability to council

and on attitudes towards adolescents and on attitudes towards adolescents

Distribution of the vouchersDistribution of the vouchers

• By the voucher agency ICAS (markets, By the voucher agency ICAS (markets, house to house, streets, outside schools house to house, streets, outside schools in poor barrios)in poor barrios)

• Through NGOs working with poor Through NGOs working with poor adolescentsadolescents

• Adolescents organizations related to Adolescents organizations related to contracted clinics contracted clinics

• Through clinics (voucher are given to Through clinics (voucher are given to pregnant adolescents for friends etc)pregnant adolescents for friends etc)

DistributionDistribution• Distribution is continuously, each month Distribution is continuously, each month

date of validity is changeddate of validity is changed• Vouchers valid for a period of 2-3 months Vouchers valid for a period of 2-3 months • DistributionDistribution

- ICAS- ICAS 81 %81 %

- NGOs- NGOs 6 % 6 %

- Clinic related youth org.- Clinic related youth org. 10 %10 %

- In clinics- In clinics 3 % 3 %

Use of vouchersUse of vouchers

• > 20,000 vouchers were distributed > 20,000 vouchers were distributed

- 56% to girls- 56% to girls

- 44% to boys- 44% to boys

• >2,000 vouchers were redeemed:11%>2,000 vouchers were redeemed:11%

- girls - girls 17 % (1,700)17 % (1,700)

- boys- boys 4 % ( 320) 4 % ( 320)

Type of services asked for*Type of services asked for*

girlsgirlsboysboys

• IECIEC 22%22% 42%42%• FPFP 32%32% 25%25%• Pregnancy test Pregnancy test 18%18% - -• Prenatal controlPrenatal control 24%24% - -• STIsSTIs 33%33% 32%32%

* more than one reason possible* more than one reason possible

Characteristics of users compared Characteristics of users compared to overall adolescents population to overall adolescents population

• Education: Education: - girls about the same - girls about the same - boys a bit higher- boys a bit higher

• Users are poorerUsers are poorer• Users start sexual activity much Users start sexual activity much

earlier:earlier:- girls mean age 15 against 18 - girls mean age 15 against 18 - 24% before age of 15 against 12% - 24% before age of 15 against 12%

Continuation characteristics Continuation characteristics

• Users are more often mother or Users are more often mother or father:father:

- girls: 34% against 20%- girls: 34% against 20%

- boys: 22% against 4%- boys: 22% against 4%

• Girls are more often pregnant Girls are more often pregnant

- 24% against 4.5%- 24% against 4.5%

Prenatal controlPrenatal control• Of female users 24% were pregnantOf female users 24% were pregnant

• 75% had never had a prenatal control 75% had never had a prenatal control

• Of these:Of these:

- 28% in their first 3 months- 28% in their first 3 months

- 57% 3 to 6 months pregnant- 57% 3 to 6 months pregnant

- 7.5% 6 to 8 months pregnant- 7.5% 6 to 8 months pregnant

- 7.5% > 8 months pregnant- 7.5% > 8 months pregnant

What we achievedWhat we achieved• Vouchers could be distributed to Vouchers could be distributed to

adolescents and were used adolescents and were used • Poorer and more needy adolescents Poorer and more needy adolescents

made more use of their vouchermade more use of their voucher• Clinics participated enthusiasticallyClinics participated enthusiastically• Medical doctors recognized inability Medical doctors recognized inability

of counseling adolescents and of counseling adolescents and welcomed trainingwelcomed training

continuation achievementscontinuation achievements

• Power of choice with consumerPower of choice with consumer

• Clinics offered services at prices well Clinics offered services at prices well below their standard rates and even below their standard rates and even below the unit costs of equivalent below the unit costs of equivalent services at MoH centers services at MoH centers

• Central procurement of IEC material, Central procurement of IEC material, medical supplies ensures efficiencymedical supplies ensures efficiency

What we hope to achieveWhat we hope to achieve

• To engender changes in the To engender changes in the provision of services based on the provision of services based on the requirements of the usersrequirements of the users

• Innovative approaches of services to Innovative approaches of services to attract adolescentsattract adolescents

• To improve human quality and To improve human quality and technical quality of existing services technical quality of existing services

In resume an adolescent In resume an adolescent voucher scheme can:voucher scheme can:

• Give power of choice to adolescents, clinics Give power of choice to adolescents, clinics with best quality are more usedwith 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 parties Can 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 Improve human and technical quality of

services contractedservices contracted

In other words; aIn other words; a voucher voucher schemes might schemes might offer 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 cheap Efficient and cheap