Day 2 at the International Conference on Global Health and your faithful blogger is officially exhausted. Non-stop sessions today mixed in with frenetic stall action and my brain is whirring. All good though and the Marie Stopes International exhibition stall was a great success.
Contrary to my predictions, everybody loved the free spikeys (free things to stop people spiking your beer in bars) and they were the centre of many colourful conversations.
The official programme started today and there was a good session on vouchers for healthcare. The panel consisted of four speakers who each outlined their particular voucher model. What struck me was how different each model was and how the concept of what a voucher is varied so much. In Nicaragua, the voucher is a free piece of paper that is given out to all teenagers in order to increase access to family planning services.
The programme literally handed out hundreds of thousands of vouchers without much targeting and the redemption rates were below 50%. This was completely different to the model in Kenya (which MSI partnered on) in which women paid a significant monetary contribution for the voucher and the redemption rates was over 80%.
Despite the differences, there seemed to be some consensus over the necessary elements to a voucher programme:
- reimbursement follows services (output-based aid)
- a network of healthcare providers is mobilised to increase access
- there is some sort of voucher circulation system (e.g. a management agency)
- promotion activities are used to generate demand
The role of the management agency is inherently complex and usually includes responsibility for accreditation and quality assurance; claims and reimbursements; marketing and internal monitoring and evaluation.
Unfortunately, corruption of some sort seems inevitable given the large amounts of money flowing through the voucher system as well as the monetary value of the vouchers. In Kenya, the vouchers are targeted for poor women.
Initially, screening took place in health facilities but it soon became apparent that people were not being entirely honest about their circumstances. The only way to actually verify the screening was to conduct a home visit which became necessary albeit expensive and time-consuming.
This challenge of targeting the poorest community members was a reoccurring theme: in Tanzania, the programme provided vouchers for insecticide treated nets (for malaria prevention) and was supposed to target the poorest of the poor but failed to do so because of financial barriers, lack of education and distance.
Reflecting upon the presentations and our own experience in MSI in managing voucher programmes, I remain optimistic that this type of demand-side financing is an important way to provide services to those who are normally excluded due to poverty or discrimination. However, we still have a long way to go before we can know whether or not such programmes are either cost-effective or sustainable.
Finally, I went to the only scheduled session with the word “abortion” in it which was on youth-friendly post-abortion care. Youth-friendly programmes in Ethiopia and Nigeria have made a real difference in increasing the rate of post-abortion family planning (from 34% to 100% in Nigeria) although in most cases, it seems that young people are walking out of the clinic with a handful of condoms rather than a longer-term solution such as an IUD or implant.
Gynuity presented on a randomised trial comparing the outcomes between misoprostol and MVA for the treatment of incomplete abortions or miscarriages in Egypt. The success rate for misoprostol (measured as complete uterine evacuation) was 98.3% compared to 99.7% for MVA – in other words, there was no significant difference between the two procedures. Moreover, women were generally more satisfied and more likely to recommend misoprostol than the standard MVA procedure.
These findings were particularly timely and cause for celebration with the recent announcement by WHO that misoprostol is now included on the essential drugs list for the treatment of incomplete abortions.
On that good note and with drooping eyelids, I will sign off. More anon.