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

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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

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