“Vouchers for Services and Supplies ”

1. “Vouchers for Services and Supplies” Christine Namayanja, Programme Director , Marie Stopes International Uganda 28th May| Reproductive Health Supplies Coalition Meeting| Kampala Uganda

2. 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.

3. What is Output Based Aid • 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.

4. At the Heart of OBA • Contracting out of service provision to an already existing service provider (third party) • 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.

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

6. 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 • actualservices provided.

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

8. Service Package

9. Voucher Distribution

10. 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

11. 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.

12. Key Lessons: Targeting New PopulationsRecipient strategy- targeted approach as opposed to a universal approach (difficult-to-reach groups, poor, high risk). Benefits 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 • 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

13. 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

14. Key Lessons: Quality Improvements Benefits 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 • 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

15. Key Lessons: Quality Improvements Benefits Potential draw backs Services may become fragmented Administration and monitoring system costs may be high • 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.