Isidore Sieleunou (AEDES & co-facilitator of the CoP Financial Access to Health Services) interviews Anna Gorter on a recent evidence review she co-authored with Por Ir (National Institute of Public Health, Phnom Penh) and Bruno Meessen (Institute of Tropical Medicine, Antwerp). The review, commissioned by the German Federal Ministry for Economic Cooperation and Development, is accessible on the German Health Practice Collection website, here (together with other documents and power points).
Your literature review is timely for the hot debate on Result Based Financing (RBF). Could you summarize its key findings?
RBF is a relative new approach in health in Low and Low-middle-Income Countries (LLMIC). It is an answer to the disappointing results of the health sectors to meet public expectations and reduce maternal, neonatal and child mortality and morbidity. Many governments are aware of the low performance of their service providers and are ready to test new approaches health. As a result a wide range of approaches has been developed, whereby payment of providers is linked to the results providers achieve.
Our review focused on maternal and neonatal health care and on the effects on the performance of health care providers. We investigated four approaches: performance based financing (PBF), performance based contracting (PBC), vouchers, and Results Based Budgeting (RBB) (also named performance-based budgeting or intra-governmental transfers). We looked at utilisation of services, quality of services, and equity (i.e. if the approach was pro-poor, reducing the rich-poor gap in access to care). There were little or no studies on cost-effectiveness or sustainability. All in all we found 70 research papers for 37 programmes, of which 27 had a rigorous design and which were used for the final conclusions.
The strongest evidence was found for vouchers, with robust evidence that vouchers can increase utilisation and quality of services, and improve equity. For PBF we found robust evidence that they can improve quality, but insufficient evidence for utilisation and equity. For PBC we found modest evidence for utilisation and equity and insufficient evidence for quality. For RBB there were not enough studies. Vouchers are a much older approach (since 1964), while PBF and PBC only started a decade ago, hence the difference in evidence.
You have been working on the voucher approach for a substantial part of your career. Which place do you see for vouchers in Africa?
For me, vouchers have always been the tool par excellence to reach disadvantaged populations with critical services, such as mother and child care, family planning, STI and HIV care, cervical cancer, etc. That is assisting the poorest or otherwise disadvantaged in using health services, which are important for their health, but which they are not using currently.
We developed the approach in 1995 in Nicaragua, basically to assist sex workers and adolescents to access sexual and reproductive health. We saw it as a way to overcome financial barriers as well as to improve the quality of care which was also an important barrier for these groups. The results were much better than we ever expected and that is when we started to analyse the reasons for this success. Vouchers provide strong incentives on the demand side (they inform, they guide, they empower the clients) as well as on the supply side (health providers are motivated to attract more clients and contracts demand also improved technical quality).
I think that vouchers do have a place in Africa, especially in targeting those populations which are currently not reached and also in driving improvements of provision of services at the facilities. In the Kenya voucher scheme we have seen that providers invest the voucher revenue in improving the functionality of their facility and increasing their capacity (sending staff to be trained in long term family planning, repairing their buildings and ambulances, buying equipment, supplies, new maternity wards and operating theatres etc.). Vouchers could be used for especially critical services, where other approaches have not worked.
In Africa, many countries have launched at the same time – sometimes in parallel – various health care financing approaches. Would it not make sense to merge them? Could you tell us what could be the effect of a combination of two or more RBF approaches, for instance PBF, Vouchers and even targeted free health services?
Combining PBF and vouchers would certainly increase the effectiveness of both approaches, although this has not be done so far. As described above, vouchers can bring in clients who need services but who even in the presence of a PBF still do not come to the health facility. Distributing the vouchers provides an opportunity to give face-to-face relevant information on particular health services and where these can be obtained. The voucher itself inspires confidence in the clients that they actually will be attended, and this is especially important for the poorest or otherwise disadvantaged groups, who often lack self-confidence. Furthermore, additional benefits can be added to the voucher such as payment of transportation costs if that is an important barrier. In that sense, a voucher program on top of a PBF scheme would enhance equity and reduce the rich-poor gap. Vouchers are in fact free health services targeted to special needy groups.
You worked a lot in Central America and more recently in Asia. Several RBF schemes documented in your review are indeed from those continents. What can Africa learn from them?
I think the most important lesson observed in my work is that in each country I visited there are huge population groups who are in need of particular health services but not use them because the access barriers are simply too great to overcome. Vouchers can assist them to overcome these barriers, both barriers at the demand side as well as at the supply side. In fact I think an important reason for vouchers to be so effective in the above described effects on utilization, quality and equity is because they alter behaviour of clients and providers at the same time. However, taken into account the many successful PBF programmes in Africa, I think there is a new role for vouchers and that is bringing in those clients who still not come. This would make the PBF programmes stronger and more effective in increasing the health of the poorest and most disadvantaged groups in Africa.