PROJECT APPRAISAL-COMMITMENT DOCUMENT
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UGANDA
PROJECT COMMITMENT DOCUMENT
Project Name: Reproductive Health Vouchers in Western Uganda (P104527)
This project aims at facilitating safe childbirth and at providing treatment for Sexually Transmitted Diseases (STDs) to Uganda’s poor. Using a voucher scheme that was initially developed by a Kreditanstalt für Wiederaufbau (KfW) pilot, this program will increase women’s access to trained medical professionals throughout pregnancy and will also provide subsidized STD treatment to poor Ugandans of both genders. 320,000 people will benefit from GPOBA’s intervention.
Geographic targeting will ensure that GPOBA funds reach the poor. Retail outlets (e.g. pharmacies and drug stores) located in proximity to target populations will sell vouchers for medical treatment at a nominal fee. Purchasers can then receive care at participating medical facilities using coupons attached to each voucher. Following treatment, a Voucher Management Unit (VMU) will reimburse medical facilities on a per-item basis after collecting appropriate documentation.
Marie Stopes International – Uganda (MSI-U), a subsidiary of a globally active reproductive health non-governmental organization (NGO), and Microcare Ltd. a local microinsurance company, will partner to form the VMU for this project. Both institutions currently serve in the same capacity under the KfW-funded pilot and are very capable of implementing this proposed scheme. GPOBA’s grant monies and KfW funds for capacity building will flow through the VMU to medical service providers who care for the target population. The VMU will also be responsible for selecting qualified service providers and for providing them with training to improve their capacity for rendering treatment.
GPOBA’s subsidy will fund two different types of vouchers for: 1) safe delivery and 2) STD treatment. Safe delivery vouchers will entitle mothers to four prenatal visits, attended child birth, one postnatal check-up visit and counseling on family planning. In the event of a complicated pregnancy, these vouchers will also cover transport to a hospital and advanced treatments such as cesarean section and blood transfusions.
Vendors will sell STD vouchers in pairs to facilitate the treatment of couples, rather than individuals. Experience shows that individual treatments tend to be insufficient and ineffectual. Each STD voucher will pay for an average of three medical visits along with relevant lab-tests and medication. All vouchers sold through this program will have multiple detachable coupons that will each correspond to one medical visit.
Under the terms of this project, care providers will receive reimbursement for services rendered in a manner similar to arrangements used by health maintenance organizations (HMOs) and other private health insurance schemes. Payment will vary for individual interventions according to the cost of each treatment. The VMU is responsible for controlling the cost per voucher in order to reach average cost targets as specified in this document. The VMU receives a part of its payments based on the number of interventions performed by service providers and therefore has incentives to encourage judicious and effective patient treatment. Likewise, the VMU’s senior management compensation plan strongly depends on this metric. This arrangement creates sufficiently strong incentives for controlling costs and achieving the envisaged numbers of treatments.
KfW will administer GPOBA funds as a fiduciary agent and will receive a compensatory fee to cover their associated costs.
MSI-U and Microcare Ltd., the two organizations comprising the VMU for this project, lack the financial resources needed to completely pre-finance service delivery. In order to meet this obligation (up to US$200,000 per month), KfW will provide cash advances to the VMU. The VMU will obtain a performance bond to mitigate operational risks associated with these cash advances. This arrangement will address liquidity risks, while simultaneously leaving the VMU to bear operational risks. The VMU is required to provide billing data for patient services to be verified by an independent verification agent.
The structure of this project shifts performance risks to service providers. Because vouchers are valid at a number of care sites, each facility must compete for patients on the basis of service quality. While GPOBA’s project framework ensures minimum standards across all providers, it deliberately omits explicit methodological instructions for service provision. Each care facility operates under its own discretion and may set staffing levels or invest in new equipment. Like any private commercial medical facility, the risks associated with these decisions rest on the individual institution. The VMU and the independent evaluator will monitor service quality and billing behavior and are authorized to exclude unsatisfactory providers from the scheme.
Total GPOBA funding requested: US$ 6,690,000
• Subsidy funding = US$ 6,000,000
• Funds for Independent verification/auditing = US$ 100,000
• KfW fiduciary agent fee = US$ 390,000
• WB supervision = US$ 200,000
Project duration: 4 years
GPOBA funding: IFC
Additional funding sources: User contribution approx.: US$ 181,000
KfW contribution: US$ 3,055,202 (EUR 2,254,000)[1]
Outputs: 110,000 safe childbirth packages including ante- and postnatal visits as well as deliveries attended by trained health workers.
100,000 people with STDs treated.
Expected beneficiaries: 320,000 people (110,000 mothers + 110,000 babies + 100,000 STD patients)
GPOBA subsidy “efficiency”:
| |Safe delivery |Safe delivery |Sexually transmitted|
| |(simple case, 85% of cases)|(complicated delivery 15% |diseases |
| | |of cases) | |
|Service delivery |US$ 33.00 |US$ 66.52 |US$ 10.00 |
|Transportation |0 |US$ 20.00 |0 |
|Variable voucher management costs (average) |US$ 2.72 |US$ 2.72 |US$ 1.87 |
|Total |US$ 35.72 |US$ 89.24 |US$ 11.87 |
| | | |(STD vouchers) |
|Average total voucher cost |US$ 43.65 | |
| |(Safe Delivery vouchers) | |
IRR: IRR calculation is not applicable as the VMU operates as not-for-profit on the basis of reimbursement of costs.
ERR: Because of the lack of a generally agreed methodology this document will exclude an ERR analysis. However it has been determined that benefits for safe delivery in Uganda, due to avoided productivity loss and benefits of increase in birth weight amount to at least US$ 117 per treatment package.
Targeting: Vouchers are sold through outlets in poor neighborhoods (geographic targeting); the project contains an element of implicit targeting, as wealthier population uses more prestigious up-market facilities.
Grant recipient: GPOBA will enter into a grant agreement with KfW and into a MOU with the GoU that states that KfW is implementing the project on behalf of the government.
Financial Management: Financial management assessment is currently being conducted by the FM specialist and will be forwarded to GPOBA in the next week. It is envisaged that KfW, based on expenditure projections, will receive advances from GPOBA, to be held in a designated account. KfW will provide an advance to the VMU against a performance bond.
Procurement: Single sourcing arrangements for KfW and the VMU have been endorsed by the Africa procurement team. A simplified procurement assessment is to be performed on KfW.
Environmental clearance: The proposed scheme has obtained all necessary clearances. A Health Care Waste Management Plan and an Integrated Safeguards Data Sheet will be published on InfoShop before the POE meeting. Additionally the Waste Management Plan will be disclosed locally.
Government endorsement: The MoH and the Health Sector Working Group that coordinate donor activity in Uganda have both endorsed this project.
Exchange rate: 1750 UGX/US$
Responses to PoE concerns
KfW and GPOBA should discuss the implementation fee. GPOBA will investigate the precedent of the Afghanistan Reconstruction Trust Fund.
According to Bernard Abeille, a current consultant and former World Bank Procurement Adviser, KfW’s fiduciary agent fee for acting as a procurement agent is reasonable. Similar fees usually average around 7%.
For the commitment paper, the exact arrangements between Marie Stopes and Microcare shall be worked out and the implications on the Bank’s procurement guidelines shall be clarified. In this respect, attention will be paid to the inclusion of the KfW pilot project and its service providers in the scheme.
GPOBA has obtained an opinion of procurement, confirming that sole source selection of KfW, Marie Stopes and Microcare was consistent with World Bank procurement rules. The pilot project and its service providers will be included in the scheme. The selection of service providers does not have implications on World Bank procurement.
The administration costs shall be explained in the commitment document. Measures to prevent fraud shall be reasonable with regard to the project’s total cost. It may be possible to cover part of the training costs through an IFC TA grant.
The commitment document outlines voucher administration costs. 37% of the VMU’s budget is dedicated to training service providers and quality assurance activities, 25% is allocated towards billing and general administration, 20% will go towards efforts that increase project awareness and the remaining 18% will fund to product marketing, sales and other costs.
Elaborate graphic designs on each voucher and a barcode system will serve as the scheme’s primary fraud deterrents. These measures will inhibit forgery and will facilitate individual voucher identification / tracking. Relative to the anticipated effectiveness of these measures, incremental costs associated with fraud prevention are relatively low.
Instead of using IFC TA grant monies, KfW will fund service provider training.
Table of Contents
A. STRATEGIC CONTEXT AND RATIONALE 1
A.1. Country and sector issues. 1
A.2. Rationale for involvement 2
A.3. Higher level objectives to which the project contributes. 2
B. PROJECT DESCRIPTION 3
B.1. Project development objective and key indicators. 3
B.2. Project components 3
B.3. Economic and financial analysis 5
B.4. Lessons learned and reflected in the project design. 8
C. IMPLEMENTATION 10
C.1. Milestones for project implementation. 10
C.2. Partnership arrangements 10
C.3. Institutional and implementation arrangements. 11
C.4. Monitoring and verification of outcomes/results 13
C.5. Sustainability 13
C.6. Critical risks and possible controversial aspects 14
TECHNICAL ANNEXES I
Annex 1: Project costs & schedule I
Annex 2: Financial management (OP/BP 10.02). II
Annex 3: Disbursement (OP/BP 12.00). II
Annex 4: Procurement (OM, July 15, 2002). III
Annex 5: Environment (OP/BP 4.01). V
Annex 6: Results framework and monitoring mechanisms. VII
Annex 7: Project preparation and supervision IX
Annex 8: No-objection of Health Sector Working Group. X
Annex 9: Definition of services covered by vouchers XI
Annex 10: Safe Delivery & STD Project Activities XIV
Annex 11: Example of a claims processing form XVI
Annex 12: Map showing the main project site in the country XVII
ABBREVIATIONS:
|AIDS |Acquired Immunodeficiency Syndrome |
|ERR |Economic Rate of Return |
|GoU |Government of Uganda |
|GPOBA |Global Partnership on Output-based Aid |
|HIV |Human Immunodeficiency Virus |
|IRR |Internal Rate of Return |
|KfW |Kreditanstalt für Wiederaufbau |
|MoH |Ministry of Health |
|MSI |Marie Stopes International |
|MSI-U |Maries Stopes International – Uganda |
|NGO |Non-governmental Organization |
|OBA |Output-based Aid |
|PRC |Project Review committee |
|SD |Safe Delivery |
|SHI |Social Health Insurance scheme |
|SP |Service Providers |
|STD |Sexually Transmitted Disease |
|VMU |Voucher Management Unit |
A. STRATEGIC CONTEXT AND RATIONALE
Country and sector issues.
With an average per capita income of US$ 250 and a life expectancy of just 48.9 years, Uganda is among the world’s poorest countries. It ranks 145th out of 177 nations in the UNDP Human Development Index and, although its health system has progressed in recent years, maternity and child health services still have serious problems.
A 2005 KfW study[2] conducted in the Mbarara region found that private and NGO-operated clinics / health posts were the population’s preferred health service providers due to their high service quality. Yet affordability and accessibility issues often inhibit poorer demographics from receiving treatment at these facilities. Furthermore, high demand for subsidized NGO and privately provided services causes long waits at such healthcare sites. A perceived untrustworthiness of Ugandan public clinics further compounds this issue. Due to their low costs, cultural acceptability and relative accessibility, traditional healers remain popular among large parts of the target population. STD positive patients are often practically predisposed toward traditional healers because of social stigmata and confidentiality / privacy issues.
KfW has launched an STD voucher scheme in July of 2006. This pilot program incorporated 15 accredited treatment facilities and included awareness raising campaigns. 44 independent vendors have sold 7,740 vouchers through this initial effort and providers have delivered 4,500 treatments already. There have been incidents of fraud, inappropriate diagnoses, and inaccurate reporting during the initial phases of this trial, which were reliably detected by the claims processing system and addressed by additional training activities, and increasingly stringent provider management.
Childbirth
In Uganda, most children are born without the help of trained health workers. In 2004/05 public sector and not-for-profit health facilities delivered 354,856 babies, representing 25% of all births – up from 19% in 2001/2002[3]. 435 out of 100,000 Ugandan women died from giving birth in 2006 compared to 505 women out of 100,000 in 2001/20002 according to a 2006 Demographic Health Survey. Current figures estimate that 88 out of 1,000 Ugandan babies die at birth.
The average Ugandan woman will endure 6.9 live births during her life. The principal direct causes of maternal mortality in Uganda are: hemorrhaging, sepsis, pre-eclampsia and eclampsia, ruptured uteri, and complications arising from induced abortions. Indirect causes include malaria, anemia, HIV/AIDS, and tuberculosis.
Sexually transmitted diseases
A 2000[4] health survey indicated that 17% of interviewed women and 6% of interviewed men had suffered from STDs within the previous 6 months. The survey also identified as one of the most pre-disposing factors for HIV infections. 6.5% of Uganda’s population is currently HIV positive.
Rationale for involvement
This project has received a no-objection form the Health Sector Working Group, the GoU’s coordinating body for international donors that are active in health. Dr. Francis Runumi, the group’s chair has provided KfW with a letter endorsing the proposed scheme (Annex 8).
Improving health is one of the primary goals articulated within Uganda’s Poverty Reduction Strategy Paper and is also a major human development pillar of the current Poverty Eradication Action Plan (PEAP 2004/05 – 2007/08).
The project is OBA in that it uses explicit subsidies targeted to the poor population in the project area. The project’s operational risks are mainly borne by small private medical service providers. Fees for services included in the voucher package are agreed upon at the start of the program and only those service providers that are able to perform the agreed intervention at costs below reimbursed fee will make a profit. Failure to provide attractive service of adequate quality will result in loss of patients and certification to participate in the project. Facilities are at liberty to decide how to provide services. They might for example invest in equipment, employ additional staff or introduce performance-based payments.
The VMU, responsible for project implementation, takes on risks, too, by partially being paid for administrative costs on a per-voucher basis. As service providers are reimbursed on a per-item basis and thus might perform unnecessary services to increase billing, a per-voucher payment provides an incentive to VMU to effectively control billing.
In the target region the percentage of child deliveries attended by skilled professionals is around 30%. In the lowest income quintile only 20% of childbirths are attended. Deliveries attended by a medical doctor are below 4%. Although many women visit a medical facility during pregnancy, very few do this regularly in the intervals recommended by the WHO. This contributes to the particularly high Maternal Mortality Rate in the target areas. The voucher encourages women to make use of the full treatment cycle. Medical facilities are encouraged to complete the cycle to receive full payment.
Higher level objectives to which the project contributes.
The safe delivery vouchers will substantially contribute to reducing maternal and infant mortality as well as increasing the overall health of newborns and children and their mothers. Regular antenatal care that allows screening the target population for risk factors during pregnancy and delivery has proven to have a huge impact on mother and child wellbeing.
The STD voucher is designed to decrease the burden of STDs in western Uganda. The treatment of high risk groups not only helps to ease the burden of those infected but also allows prevention of transmission.
The project will have a positive impact on the Ugandan health system. Lessons learned and the infrastructure build by the project could be integrated in the Ugandan health care system. Contracting/voucher schemes in other countries have shown a potential to increase efficiency over typical input-based public health care systems, thus reaching a greater number of people with a given amount of public expenditure.
Additionally, the KfW-financed capacity building components will increase the overall skill level of health workers participating in the project. On-going evaluation of service provider performance allows tailored on-going training to improve quality and address specific training needs.
Experiences with voucher systems have also shown that voucher beneficiaries tend to return to private medical facilities for other needs of medical attention, after utilizing vouchers. This is attributed to the fact, that patients get used to improved medical services provided by skilled professionals and prefer them over alternative solutions, such as traditional healers.
B. PROJECT DESCRIPTION
Project development objective and key indicators.
The project’s overall objective is to reduce the number of mothers and children dying or being disabled due to absence or underutilization of skilled medical attendance and to reduce the burden of sexually transmitted diseases. To ensure the quality of medical services, participating service providers will be certified to be able to provide services included in the treatment package at a predetermined quality.
More specific objectives include:
A. Improve the VMU’s and service providers’ capacity to fulfill their roles in the program (KfW-funded capacity building component)
– Select service providers and improve their capacity to provide adequate services trough tailored training
– Advertise the project to the target group in order to create a demand for vouchers and engage in general awareness raising activities related to reproductive health
– Increase the voucher management unit’s ability to manage the project
B. Increase the number of deliveries attended by skilled medical professionals
– Decrease maternal and infant mortality due to the lack of skilled attendance at child birth
– Reduce the number of disabled children due to a lack of skilled attendance at child birth
C. Provide treatment for STDs
– Decrease the individual burden of people suffering from STDs
– Decrease productivity lost due to STDs
– Prevent transmission by targeting specifically high-risk target groups
The voucher approach was chosen because it gives the possibility to better market the scheme and to target sales to poor areas. Additionally, it controls the overall project costs, as they are limited to the amount of vouchers sold. The alternative of certifying healthcare providers and reimbursing them on the basis of patient records would carry the risk that the number of treatments exceeds the number budgeted for.
Project components
The project has three main components:
A. The KfW-funded capacity-building component of US$ 1,607,628, dedicated mainly to financing fixed-cost components of the scheme like:
– an information, education and communication campaign (US$ 425,174)
– service provider quality assurance and training (US$ 770,889)
– capacity building in voucher administration and billing (US$ 370,026)
– Other expenses (US$ 41,539)
B. 110,000 safe child birth deliveries by trained staff at an average cost of US$ 43.83 per delivery
The package includes:
– Costs associated to the safe delivery cycle (for detailed list of services covered, please see Annex 9):
o Antenatal care: 4 visits;
o Normal and complicated deliveries, including cesarean sections and other emergency interventions and postnatal monitoring up to three days
o One postnatal visit, including family planning counseling
– Cost associated with marketing and sales of vouchers
– Variable and some fixed costs associated with voucher administration and billing
C. 100,000 people with STDs treated at an average cost of US$ 11.87 per treatment
The package includes:
– Costs of treatment of STDs, including the number necessary for completing the treatment cycle for the specific diagnosed disease (for detailed list of services covered, please see Annex 9)
– Cost associated with marketing and sales of vouchers
– Variable and some fixed costs associated with voucher administration and billing
Table 1: Voucher costs
| | Year 1 | Year 2 | Year 3 | Year 4 | Total |
| STD Vouchers |
| Cost per voucher (US$) |12.99 |12.25 |11.74 |11.08 |11.87 |
| Number of vouchers |18,000 |22,500 |27,000 |32,500 |100,000 |
| Total voucher costs (US$) |233,820 |275,625 |316,980 |360,100 |1,186,525 |
|Normal Safe Delivery Vouchers |
| Cost per voucher (US$) |37.31 |36.59 | 35.84 | 34.67 |35.72 |
| Number of vouchers |12,810 |17,934 | 25,620 | 37,576 |93,939 |
| Total voucher costs (US$) | 477,938| | 918,215 | 1,302,752 | 3,355,105 |
| | |656,201 | | | |
|Complicated Safe Delivery Vouchers |
| Cost per voucher (US$) |90.83 |90.11 | 89.36 | 88.19 |89.24 |
| Number of vouchers |2,229 |3,121 | 4,458 | 6,538 |16,346 |
| Total voucher costs (US$) |202,469 |281,209 | 398,384 | 576,646 |1,458,708 |
|Overall safe delivery vouchers |
| Cost per voucher (US$) |45.24 |44.52 | 43.77 | 42.60 |43.65 |
| Number of vouchers |15,039 |21,055 | 30,078 | 44,114 |110,286 |
| Total voucher costs (US$) |680,407 |937,410 | 1,316,599 | 1,879,398 |4,813,813 |
| Total Subsidy (US$) |914,227 |1,213,035 | 1,633,579 | 2,239,498 |6,000,338 |
In order to be certified to participate in the program, the capacity of medical facilities to provide adequate services will be evaluated by the VMU. Quality assurance will be provided by a contracted independent evaluator, performing regular monitoring visits to examine the quality of service provisions of the providers. When indications of quality problems in individual facilities are observed, additional training and supervision will be scheduled. On-going lack of quality will lead to exclusion from the scheme.
Targeting
The project targets poorer strata of the population living in the catchment areas of approved providers in the greater Mbarara region in western Uganda (see Map in Annex 12). The program will be based around providers and will not necessarily cover the whole population of a particular district or geographical region.
Voucher sales will target rural and poor urban environments, mostly at drugstores and pharmacies as such institutions are widespread, deemed trustworthy by the target group and, in the case of STD vouchers, are considered non-stigmatizing in the same way private health service providers are.[5] Additionally, publicity campaigns will specifically target the poor population. The fact that the wealthy population in developing countries tends to use private up-market medical facilities adds to the focus of the project on the poor population.
Additionally, STD vouchers target the poor high-risk population such as truck drivers and sex workers. For this target group, stigmatization by public health institutions tends to be a reason for not seeking medical help.
Economic and financial analysis
Costing of the voucher
The calculation of voucher costs is based on consultation fees, lab testing, drugs to be provided according to a treatment algorithm and administration costs of the voucher management unit. Costs for specific interventions, lab testing and medication are calculated based on Microcare’s experience in the market.
Service provider cost:
As in a private medical insurance or health management organization, disbursements to service providers will be made based on a fee for services, performed on a per-item basis, reflecting actual costs instead of a lump sum per patient. Medical consultations are reimbursed at US$ 2, medication, lab testing and more complicated interventions, such as pregnancies are not reimbursed on a fixed value, but on a value that reflects the services performed. Some of the numbers stated in tables 2 and 3 therefore are averages of cost per intervention.
The fee for service arrangement is considered necessary in order to protect small medical service providers, who might run in financial difficulties if they attracted a disproportionately high number of more complex cases. If the service providers would be reimbursed with a fixed sum per vouchers, they would be forced to provide sub-standard services in order not to lose money or face bankruptcy if they provided more extensive services.
However, for the project the fee for service arrangement implies a risk of providing service providers an incentive of drive up bills by performing unnecessary interventions (a problem frequently encountered in health systems of developed countries in similar circumstances). This risk is mitigated by the fact that the VMU is partially paid on a per-voucher-basis and that management salaries are dependent on the number of people treated. The VMU therefore has a strong incentive to maximize the number of patients treated, which only is possible if costs per treatment can be controlled. The claims processing software used by the VMU provides capabilities of identifying unusual billing behavior by individual service providers and thus gives the VMU the possibility to control expenditures.
Table 2: Costing of SD voucher
| |Ante-natal visits |Treatment of |Safe delivery |Post-natal|
| | |malaria & other |(average) |visit |
| | |illnesses | | |
| | |(average) | | |
|STD |Number |3 |1 |1 | |
| |Unit cost (US$) | 2.00 | 4.00 |1.87 | |
| |Total cost per voucher (US$) | 6.00 | 4.00 |1.87 | 11.87 |
VMU cost:
The proposal as presented in the eligibility note was to reimburse the VMU for all cost incurred on a per-voucher-basis. This has proven to be unrealistic, as the VMU does not have the means to pre-finance the substantial cost associated with the public awareness raising campaign, the service provider training and the investment in administration and billing infrastructure. These tasks require substantial up-front investment in capacity building, which the VMU is not able to do on its own. This capacity building will be funded with KfW funds.
However the VMU will be paid output-based on a per-voucher-basis for costs incurred related to voucher marketing and sales as well as a part of costs related to voucher administration and billing. This is an innovation compared to the pilot project and other voucher schemes where management units were paid based on inputs.
The total VMU cost of US$ 2,093,310 represents 28% of the overall direct project implementation cost. This is explained by the relatively high cost of managing relations with numerous service providers – the VMU is expecting up to one million invoices to be processed – and the fact that the project requires substantial capacity building and awareness-raising in order to be successful. The variable administration costs borne by GPOBA as part of the per-voucher costs are only 6% of the costs for medical treatments.
Table 4: VMU budget
|Description of activities |TOTAL |Variable reimbursement |Fixed reimbursement |
| | |(GPOBA funded) |(KfW funded) |
|1. Information, Education and|$425,174 | $0 | $425,174 |
|Communication | | | |
|2. Voucher Marketing & Sales |$336,755 | $336,755 | $0 |
|Costs | | | |
|3. Service Provider Quality |$770,889 | | $770,889 |
|Assurance & Training Costs | |$0 | |
|4. Voucher Administration & |$518,953 | $148,927 | $370,026 |
|Billing Costs | | | |
|5. Other |$41,539 | $0 | $41,539 |
|Total |$2,093,310 | $485,682 | $1,607,628 |
Co-payment
As in the pilot project, the STD vouchers will be sold through pharmacies and drugstores.
SD vouchers will be sold at a cost to the consumer of between 1,000 Ushs (US$0.57) and 2,000 Ushs (US$1.14) and STD vouchers at 1,500 Ushs (US$0.85) per voucher. STD vouchers will only be sold in pairs in order to encourage treatment of partners, rather than only one person.
The resale pricing of vouchers is based on the experience of the pilot project, taking into account willingness to pay and affordability. Since the start in June 06, the project has treated close to 5,000 clients in four districts in south-western Uganda.
Economic cost-benefit analysis
The valuation of lives saved by medical interventions is a controversial topic and the estimation of lives saved or illnesses prevented or cured has methodological limitations. In the World Bank discussion paper “Estimated Economic Benefits of Reducing Low Birth Weight in Low Income Countries” of 2004 the economic benefits of interventions targeting low birth weight, one of the targets of the safe delivery voucher, was valued at US$ 97.50. A WHO publication[6] on the cost of illness and mortality, caused by lack of skilled attention at birth, values the productivity loss of early maternal deaths, maternal disability and child death at US$ 850, US$ 314 and US$ 1,248 for Uganda.
Based on these numbers and conservative estimates for the reduction in maternal deaths, disability and infant mortality, the productivity loss avoided for each SD voucher is at least US$ 78.84 (see Table 5: Estimated reduction in productivity losses per voucher). As some of the benefits from reduction in low birth weight might contribute to a reduction in child death, summing the total identified benefits of US$ 97.50 to the benefits of avoided productivity loss might result in double-counting. Therefore only incremental benefits of targeting low birth weight[7] have been added to determine the total identified minimum benefit per voucher. The result compares favorable to the expected costs of complicated delivery of US$ 89.24.
Table 5: Estimated reduction in productivity losses per voucher
| |Per-case |Expected |Productivity Loss |Benefit per voucher |
| |probability[8] |reduction[9] |(US$) |(US$) |
|Maternal mortality |0.51% |90% | 850 | 3.86 |
|Child death |8.80% |50% | 1,248 | 54.91 |
|Maternal disability |10.23% |50% | 314 | 16.06 |
|Total |74.84 |
|Incremental value of interventions targeting low birth weight |42.59 |
|Total minimum benefit per voucher |117.43 |
The “Reproductive Health Cost Literature Review” (Mumford et al., 1998) gives some comparable cost for health interventions in developing countries. According to the review, a delivery in Bolivia cost US$27.91 in 1991 (caesarean section US$56-104) without antenatal or postnatal visits. In the case of The Gambia, individual visits during pregnancy cost between US$ 14.77 and US$38.05. The cost of treatment of sexually transmitted diseases in various developing countries, quoted in the review, was between US$20 and US$30 per intervention. This suggests that the voucher costs proposed for the Uganda health voucher project are not unreasonable.
Lessons learned and reflected in the project design.
This would be the first GPOBA voucher scheme. Voucher schemes are similar to health insurance projects in many ways. In OBA-type health insurance projects “money follows the patient” which means that patients choose a service provider of their liking. Co-payments, in analogy to the voucher fee, are common in health insurances. Voucher schemes as the one proposed are compatible with health insurance projects and might be instrumental in the build-up of cost-efficient and stable health insurance programs.
Mbarara, Kiruhura, Isingiro and Ibanda. The pilot was officially launched on 29th July 2006 and will run until September 2007.
Project results to date include:
➢ Over 20 treatment facilities accredited with 15 OBA STD Treatment Centers currently active
➢ Service providers (SPs) trained in clinical diagnosis, laboratory diagnostic techniques and the treatment of STDs
➢ Social marketing activities conducted to promote voucher distribution points and OBA treatment sites, e.g. community sensitization sessions and radio talk shows
➢ 7,740 vouchers distributed by 44 vendors resulting in over 4,500 individuals treated
➢ 3,162 claims processed and service providers reimbursed
➢ Comprehensive Voucher Management Unit System developed for the pilot (see Annex 11: Claim Form), which is being used to manage voucher distribution and claims data, report on utilization trends and costs and flag potential cases of fraud or abuse.
The pilot initially encountered problems with 60-70% of claims being quarantined due to inappropriate diagnosis and treatment, inaccurate reporting of claims or fraud. To counter this problem, two physicians and a trained nurse were brought in to enhance quality assurance and manually vet claim forms, which has been successful in dramatically reducing the number of unpaid claims.
Vouchers will be modeled on those used during the pilot and will incorporate a number of improvements based on lessons learned. As in the pilot, STD vouchers will be bifurcated with one section for the client and a second section for a partner. The total cost of two vouchers for a couple will therefore be 3,000 Ushs (US$1.70). Safe Delivery vouchers will be designed to accommodate the four antenatal visits on average plus delivery and follow-up. Both vouchers will be durable and difficult to reproduce fraudulently. They will include:
➢ Sectional design for multiple visits. For Safe Delivery this is likely to enable mothers to attend antenatal visits at different clinics if required
➢ Clear instructions in English and the languages of the targeted regions
➢ Contact information for questions and feedback
➢ Bar-codes for tracking, reporting, and cost containment
➢ Clearly displayed prices.
Additionally, a standardized approval system for private practitioners participating in the project as well as a quality assurance system that works based on an IT claims processing software will help to monitor and improve service delivery. Experience with the pilot show that the IT system helps to better target the capacity building budget to where it is used most efficiently, because it highlights problem areas.
Uganda, especially the MOH, is open for private service delivery in the health sector. The experience could trigger a shift towards performance-based payments in the public health sector. The scheme will showcase the possibilities to use small scale private providers, particularly in difficult to serve rural areas, to provide health care services.
C. IMPLEMENTATION
Milestones for project implementation.
|Milestone |Expected completion |
|GPOBA provides panel endorsement |June 2007 |
|GPOBA provides funding commitment |July/August 2007 |
|Project design finalized |August 2007 |
|GPOBA Consulting Agreement signed |August 2007 |
|Contracts signed between KfW and GoU |September/October 2007 |
|Contract singed between GoU and VMU |September/October 2007 |
|Service provision begins |October 2007 |
|Subsidy disbursement begins |October 2007 |
|Subsidy disbursement ends |October 2011[10] |
Partnership arrangements
The project will be co-financed and implemented jointly by GPOBA and KfW. GPOBA and KfW will enter into a grant agreement. As KfW will be supervising the project and act as fiduciary agent on behalf of GPOBA, GPOBA will pay KfW a fiduciary agent fee of US$ 390,000 (6.5% of the GPOBA subsidy). KfW will hold a designated account into which GPOBA would disburse half-yearly, based on forecasts for forecasts for funds needed.
KfW will fund capacity building activities necessary for the project. Its main contributions will be in the areas:
• Service Provider Quality Assurance & Training Costs (US$ 770,889)
• Information, Education and Communication (US$ 425,174)
• Voucher Administration & Billing Costs (US$ 370,026)
KfW’s fund will also finance:
• External supervision (US$ 407,436)
• Backstopping and consultancy of the London-based NGO Mary Stopes International for the project (SU$ 260,000)
Additionally KfW will hold US$ 786,138 for contingencies that may arise.
KfW will enter into an agreement with the MoH stating that KfW administers funds of the German bilateral development cooperation on behalf of the GOU. KfW will act as procurement agent for the MoH, selecting the VMU and – in cooperation with GPOBA – the independent verification agent.
Institutional and implementation arrangements.
Voucher Management Unit
The VMU is comprised of two institutions, MSI-U and Microcare limited. MSI-U is a NGO specializing in reproductive health. It is a local subsidiary of London-based Marie Stopes International (MSI) that is active in health care in developing and developed countries.[11] MSI is retained by KfW as consultant to advise the project on specific issues of medical service provision and specification.
The second institution is Microcare Health Ltd, and its subsidiary Microcare Insurance Ltd, are leading providers of health management and insurance services to the corporate sector in Uganda. Microcare has also been at the forefront in developing community based health micro insurance. Microcare is internationally recognized for its innovative solutions and its reliable medical and insurance IT management systems. In the pilot project, Microcare developed and implemented the bar code generation and tracking systems and the database program.
Responsibilities of the program are distributed between the two institutions as laid out in the following figure:
Figure 1: Administrative setup of VMU
[pic]
For a list of activities related to the VMU tasks, please refer to Annex 10.
Service Providers (SPs)
Service Providers will be accredited through the voucher scheme to provide safe delivery and/ or STD treatment. SPs will provide health care services, maintain treatment records and send vouchers and claims documentation to the voucher unit. As public health facilities are forbidden to charge user fees (including the voucher co-payment), only private operators (for-profit and not-for-profit) can participate in the project. In the pilot, 82% of the participating service providers are for-profit and 18% are private not-for-profit.
Vendors
Distribution of vouchers will take place through pharmacies, health facilities, community-based and faith-based organizations as other locally relevant institutions that serve the target population. Voucher outlets will receive a commission of approximately US$0.10 per voucher.
Peer Review Committee (PRC)
A Peer Review Committee will be established during the set-up phase of the project expansion in order to provide expert technical guidance and support. The PRC will be represented by members of the MoH, private, public and not-for-profit sectors and well as service providers and consumers. The PRC will meet once or twice a year to review the progress of the project with the Strategic Oversight Team and their input will be incorporated into the ongoing planning and development of the program.
Independent verification and evaluation agent
KfW and GPOBA will jointly select an independent verification and evaluation agent utilizing the Bank’s eConsult and enter in two separate contracts with it. The GPOBA contract with the verification agent will be Bank executed.
The agent will execute a KfW-funded impact evaluation of the project and also audit the VMU’s reports that trigger disbursement of OBA payments on a quarterly basis. KfW will sign the contract with the agent on behalf of the MoH, as KfW has been appointed procurement agent by the MoH for the proceeds of bilateral aid used for the project.
Figure 2: Project setup
[pic]
The project’s operational risks will be shared between the medical service providers and the VMU. The providers of medical services that participate in the program are mainly for-profit operators. They are free to decide how to provide the pre-defined services included in the voucher. Although service providers might be using spare capacity in their already existing facilities, the project provides an incentive for additional investment. The program has already had first contacts with micro credit banks which might be willing to invest in private health service infrastructures.
The VMU will have to incur in costs related to voucher production and sales, as well as voucher administration up-front. They will only be able to recover that cost if vouchers are actually sold and output delivery has been confirmed by the independent verification agent. Given that the numbers of interventions that can be performed at the fixed budget depend on the average cost per intervention, the VMU also risks a reduction in income if it cannot control the average cost per patient.
Monitoring and verification of outcomes/results
KfW and GPOBA will jointly select an independent verification agent that will perform an impact analysis of the project as well as audits of the VMU’s documentation of interventions performed on a quarterly basis. For GPOBA purposes these audits will contain an evaluation of a statistically valid sample of patients regarding the following points:
– Number of STDs diagnosed and treated, including an electronic version of billing documentation for all interventions billed
– Number of normal and complicated deliveries attended, including an electronic version of billing documentation for all interventions billed
– Utilization of complete treatment cycle offered – time between treatments
– Adequacy of treatment, technical quality
– Customer satisfaction based on exit interviews
– Incidents of fraudulent billing or excess treatment
Sustainability
The GoU is clearly acknowledging the advantages of OBA over input-based approaches and is considering funding the scheme after the implementation period as a method to reach particular population groups or to target specific conditions.
Other bilateral and multilateral donors are interested in the OBA approach and the results. If these are positive, they would consider supporting the baseline research concerning safe motherhood, the training of service providers as well as the subsidies. It is planned to arrange contracts in a way that allows other donors to join the program.
The GoU is considering introducing a country-wide Social Health Insurance scheme (SHI): if implemented, these services could be included in the SHI. Many of the activities in the OBA scheme including accreditation/approval of providers, defining clinical conditions, claims processing will also be needed in any insurance-based scheme and the program will provide valuable insights into how to make the system work. The sophisticated component of the claims processing and information generation is of particular importance in health projects.
Critical risks and possible controversial aspects
|Risk |Mitigation |
|Inadequate control systems within the VMU /|External financial and organizational audit of the VMU. VMU files are to be verified on the |
|Collusive behavior within the VMU itself |basis of a statistical sample. |
|Collusive behavior of patients and service |Service providers have to provide the VMU with the original voucher in order to be paid. |
|providers |Service providers are required to keep standardized medical records and provide them to the |
| |VMU upon request for auditing. There is a plausibility check on the claims database in order |
| |to identify claims patterns that might suggest collusive behavior. |
|Vouchers are traded |This is not considered a problem, as long as vouchers are traded within the target group. |
| |Given the targeting implied in the choice of down-market facilities, voucher sale to |
| |wealthier strata of the population is not expected to be an issue. Also the price of the |
| |voucher is printed on it, so that on-sale is not expected as long as vouchers are sold at |
| |face value through voucher outlets. To further reduce the risk of voucher trading, the number|
| |of vouchers sold is limited to one per customer. |
|Vouchers are counterfeit |The vouchers are individually identified by a barcode and will be blocked once turned in. The|
| |voucher design contains anti-counterfeit features. |
|Reluctance of population to accept vouchers |Social marketing campaigns will reach out to the target population. Experience with the |
| |current STD voucher scheme has been positive. |
|Lack of qualified service providers |A TA component financed by KfW, as well as part of the voucher subsidy will provide funds for|
| |capacity building. |
TECHNICAL ANNEXES
Project costs & schedule
Table 6: GPOBA funding
|Expenditure categories |Local |Foreign |Total Cost |
| |(US$) |(US$) |(US$) |
|Projected subsidy expenditure |0 |6,000,000 |6,000,000 |
|(GPOBA W3) | | | |
|GPOBA/Bank supervision |0 |200,000 |200,000 |
|Independent verification agent (GPOBA W3) |0 |100,000 |100,000 |
|KfW fiduciary agent fee (contributed |0 |390,000 |390,000 |
|funds) | | | |
|Total costs |0 |6,690,000 |6,690,000 |
Table 7: Project budget
|Item |GPOBA |KfW (FC) |Total Cost (in |% |
| | |(in €) |US$) | |
|1. Backstopping/ Consultancy MSI | |€191,441 |$260,000 |2.87% |
|2. Management Agency – MSI-U/Microcare (fixed | |€1,183,716 |$1,607,628 |17.74% |
|reimbursement) | | | | |
|3. Management Agency – MSI-U/Microcare (variable |$485,682 | |$485,682 |5.36% |
|reimbursement) | | | | |
|Subtotal | | |$2,353,310 | |
|Management / Consultancy | | | |25.97% |
|4. Safe Motherhood Voucher |$3,100,000 | |$3,100,000 |49.82% |
|5. Complicated deliveries |$1,084,318 | |$1,084,318 | |
|6. Emergency Transport |$330.000 | |$330.000 | |
|7. STD Voucher |$1,000,000 | |$1,000,000 |11.04% |
|Subtotal – Service Cost | | |$5,514,318 |60.86% |
|8. External Supervision | |€300,000 |$407,436 |4.50% |
|9. Contingency | |€578,843 |$786,138 |8.68% |
|Total US$ | | |$9,061,202 |100% |
|Contribution GPOBA |$6,000,000 | |$6,000,000 |66.22% |
|Contribution KfW | |€2,254,000[12] |$3,061,202 |33.78% |
Financial management (OP/BP 10.02).
A financial management capacity assessment is to be performed for KfW, MSI-U and Microcare. All three institutions have submitted the relevant questionnaires, which are currently being reviewed by the team’s FM specialist.
KfW will act as a fiduciary agent for GPOBA. GPOBA will disburse semi-annual advances into a designated account, based on the number of treatments projected by the VMU.
The VMU will request advances by KfW based on expected need of disbursements. KfW will only disburse money to the VMU after the VMU has provided a performance bond as a guarantee.
Payment from the VMU to the service providers is conditional on service providers making available relevant documentation and the VMU vetting claims. The VMU will provide KfW and the verification agent with an electronic file for all interventions billed and vetted.
Figure 3: Fund flows
[pic]
Disbursement (OP/BP 12.00).
Disbursement Annex to be provided by LOA.
Procurement (OM, July 15, 2002).
1. The 2004 (revised on October 2006) Bank’s Guidelines will apply;
2. KfW is considered uniquely qualified to handle the procurement process as described below:
KfW's be selected on a single-source basis as grant recipient/fiduciary agent. The project is currently structured as follows[13]:
GPOBA (WB) would enter into a Grant Agreement with KfW for administering the funds. GPOBA would also enter into a MOU with the GoU, stating that KfW implements the project on the GoU’s behalf. KfW would act as a fiduciary agency, using two consulting firms in the field to manage project execution on a daily basis. The Grant Agreement would stipulate that selection and payment of service providers funded by GPOBA subsidy would be carried out in accordance with the Bank's Guidelines for Procurement under IBRD loans and IDA Credits (May 2004, revised in October 2006). KfW's responsibility would be remunerated at an amount of US$390,000 (6.5% of the total US$6 million GPOBA subsidy applied for).
Situation: The GPOBA project envisaged builds upon an existing KfW intervention. The original pilot scheme upon which the GPOBA project is based and for which the project is a natural continuation, was developed and implemented by KfW. The proposed GPOBA project will benefit from EUR 2m from KfW. This money comes from remaining funds of the pilot and has to be spent in the first year of the project.
The GPOBA project proposes to use KfW as the fiduciary agent. The EUR 2m contributed by KfW cannot be spent to fund KfW administrative costs, due to a decision by the German government to withdraw from the health sector in Uganda in the context of donor coordination. Therefore KfW requires having the necessary operating funds to enable the project to meet its objectives after the first year. The costs are estimated to be US$390,000, an amount which is not a commercial fee but rather a fee to cover KfW’s real costs.
Assessment: Procurement guidelines section (3.9) suggests that “the justification for single source selection shall be examined in the overall interest of … the project and the Bank’s responsibility to ensure economy and efficiency and provide equal opportunity to all qualified consultants”.
Given that KfW is a not for-profit enterprise and their proposed remuneration is based on their internal costing tool, it can be assumed that their fee is economic and efficient. As the project builds on an existing pilot and uses its infrastructure there are no other qualified consultants which could be efficiently invited to provide the services required.
(3.10(a)) The task is a natural continuation of previous work not funded by the World Bank (therefore section 3.11 does not apply). KfW will build on their relationship with the consultants and the specifications of the sexually transmitted disease voucher will be directly based on the pilot project experience.
(3.10(d)) KfW has experience of exceptional worth based on the fact that they are currently implementing the pilot project. A similar project has not been undertaken by anybody in Uganda or the region, thus there is no realistic alternative to provide the required services.
(3.12) Given the fact that the project is a natural continuation and KfW has experience of exceptional worth, and therefore a competitive process is not practicable.
3. Independent Evaluator + Audit
1. GPOBA would competitively select and contract the independent evaluator using the least-cost selection method as described in para #3.6 of the Bank's Guidelines for Consultants.
2. The assignment would include two missions, with two separate contracts. One mission contracted out by GPOBA for the independent evaluator, and another contract for the audit, under a separate contract with KfW or the MoH.
3. GPOBA would associate a procurement specialist and KfW in the evaluation panel.
4. KfW would be consulted at key steps: (i) preparation of short-list; (i) preparation of RFP; (iii) technical evaluation; and (iv) contract award decision.
4. Procurement Capacity Assessment
Since the implementation arrangements would be a continuation of the KfW pilot program, a Procurement Specialist will conduct a simplified assessment, showing that the previous arrangements have proven to be efficient. The assessment is expected to be done not sooner than mid-June due to the workload of the Procurement department.
5. Acceptability of the sole source for the 2 implementing agencies (VMU) based on continuity and good prior performance:
Mary Stopes and Microcare are the two implementing agencies (jointly referred to as Voucher Management Unit) that are currently implementing the pilot project. Those firms were selected by KfW with no discrimination for country eligibility, using procedures acceptable under Bank financing, since it represent a natural continuation of their previous satisfactory assignment during the KfW-financed pilot project. They have built the infrastructure of voucher processing for the pilot and do have build the relationship with the participating medical service providers (actually they have negotiated the agreements with service providers for the pilot project). The VMU is providing KfW and GPOBA with a proposal outlining the costs for voucher management. Initial conversations indicate that the VMU fees will be substantially lower than those of pilot, as the VMU can build on existing infrastructure and experience.
The Voucher does not involve procurement and will be based on an Operational Manual acceptable to the Bank. The contracts to be signed between the VMU and service providers will be acceptable to the Bank as well.
Environment (OP/BP 4.01).
The GPOBA Reproductive Health Vouchers in Western Uganda intends to improve reproductive health services by selling vouchers for access to safe child birth services and treatment of Sexually Transmitted Diseases (STDs). The objective for the voucher system is to improve mother and child health, fight maternal mortality, and to effectively treat STDs.
The vouchers will be made available at a nominal price, marketed through existing points of sale such as pharmacies, to targeted poor populations in western Uganda. Vouchers can be purchased at a subsidized price which will allow the holder to access treatment at any certified medical facility of their choice. The retail price of the vouchers will be low enough to be affordable to the target group, but high enough to constitute an incentive of using the vouchers once they are purchased.
Holders of safe delivery vouchers are entitled to a series of ante and post natal medical visits as well as delivery attended by a trained medical professional. Safe delivery vouchers include the treatment of complicated deliveries, including cesarean sections, where needed. In the case of STDs, the voucher holder is entitled to diagnosis and treatment of any STD eligible under the project according to the national treatment algorithms. Every voucher is valid for the number of visits necessary to complete treatment.
Participating service providers compete for patients and are paid on the basis of vouchers and documentation of treatment provided. In order to be a certified provider within the voucher scheme, participating service providers will be required to have adequate means of medical waste disposal. To this end, a Health Care Waste Management Plan which follows the “Health Care Waste Management Guidance Note”, published by the World Bank’s Human Development Network in May 2000, has been developed which can be easily implemented by small scale clinics with minimal staff and resources. The waste management plan will be part of the contractual arrangements between the voucher system and service providers.
The Voucher Management Unit (VMU), which will include Marie Stopes International Uganda and Microcare Health Ltd., will be responsible for controlling the implementation of activities designed to prevent and/or mitigate potential negative impacts of waste management. The VMU will engage in awareness raising activities and training with all participating service providers to foster understanding of problems related to the treatment of medical waste. The training would include: basic information about health care waste and risks of poor management, information on the facility’s waste management plan, identifying employee responsibilities and roles in waste management, and technical instruction on application of waste management practices.
Facilities with a staff of five or more people will designate a person, or persons, responsible for medical waste management. This responsibility would be shared among all staff for facilities with less than five employees. In order to isolate harmful waste a three bin system, each with specified color, to ensure proper disposal. One bin would contain general health care waste, the second for potentially infectious waste, and a third rigid, tamper proof container for sharps. These bins would be collected and disposed of at least once a day.
As incineration is often poorly managed, and ineffective, by smaller clinics, it is recommended that small facilities do not incinerate and instead bury medical waste in a lined pit located in a secure area which will not impact humans or the environment. If a landfill area is to be utilized, the medical waste must be disposed of in a designated area within the landfill which will not be accessed by scavengers. Hazardous chemical waste and cytotoxins will not be buried and instead be returned to the original supplier or incinerated at a central certified facility.
Results framework and monitoring mechanisms.
Preliminary proposal for quarterly report. GPOBA reporting requirements for health projects have to be specified.
1. EXECUTIVE SUMMARY
1.1 Voucher Sales
• ---------- STD vouchers sold.
• ------------Safe Delivery Vouchers sold.
• -------------no. of providers reimbursed.
• Total income for Period:
1.2 Activities
• ----------------------service providers signed up provided treatment to OBA clients.
• From the start of the project until ………..,…..distributors have been signed up
• ……….STD clients treated (assumed from number of claims submitted).
• ------------SD clients enrolled.
• …………STD vouchers sold since expansion phase.
• ……………SD vouchers sold since inception of expansion phase
• IEC/BCC activities
• Other External relations activities.
2. DETAILS OF REPORT
2.1 Background
2.1.1 Key statistics - SRH and HIV/AIDS in Uganda
2.1.2 Policy issues.
2.1.3 Current Issues
2.1.4 Activities of other donors
2.2 Project Implementation Issues
2.2.1. Safe delivery Component
2.2.2 Target performance comparison
Voucher Sales.
• Graph: Budgeted vs. Actual STD vouchers safes for this quarter.
• Graph: STD treatment Vs. Follow visit type ( 1st, 2nd, etc)
• Graph: Budgeted vs. Actual Safe delivery vouchers safes for this quarter.
• Graph: Comparison of visits antenatal (visit 1, 2, etc.)
• Graph: Comparison of Voucher STD sales by areas.
• Graph: Comparison of Voucher Safe Delivery sales area.
• Comparison of Normal deliveries vs. complicated deliveries.
• Comparison of STDs by syndrome.
• Comparison areas by no. of Clients treated from those areas
• Comparison of clients treated by service providers.
• Comparison of clients enrolled vs. service providers.
• Deliveries done Vs. Service Provider.
2.2.3 Time Schedule
2.2.4 Total Cost and Financing Plan – Finance Report (Tables will be provided in this section)
Notes on expenses
2.3 Details on Activities
2.3.1 Service providers and project progress
2.3.2 Agreement on quality specification and training measures given to health care providers
2.3.3 Challenges and difficulties encountered
2.3.4 Accounting and payment procedures of the Voucher Management Agency (VMA)
2.3.5 Improvements in access to health care providers
3. Appendix: Annual Work plan.
Project preparation and supervision
Institutions responsible for project preparation
1) World Bank (GPOBA)
2) KfW
Primary contact:
Martin Schmid, Senior Project Manager
3) Implementing agency:
Marie Stopes International, Microcare Ltd.
Primary contact:
Christine Namayanja – Program Director, MSI Uganda
Dr. Gerry Noble, Medical Director Microcare Group
World Bank team
|Name |Title |Unit |
|Carmen Nonay |TTL |GPOBA |
|Lars Johannes |Operations Specialist |GPOBA |
|Olaf Smulders |Peer Reviewer |GPOBA |
|Richard Olowo |Procurement Specialist |AFTPC |
|Patrick Piker Umah Tete |FM Specialist |AFTFM |
|Serigne Omar Fye |Environmental Safeguard Specialist |AFTS1 |
|Kristine Schwebach |Operations Analyst |AFTS1 |
|Edith Mwenda |Legal Staff |LEGAF |
| |Disbursement | |
| | | |
Advisory Team:
|Name |Title |Role |Unit |
|Patricia Veevers-Carter |Program Manager |Peer Review/ Advisory |GPOBA/FEU |
|Irving Kuzynski |Panel of Experts |Advisory |GPOBA |
|Alejandro Jadresic |Panel of Experts |Advisory |GPOBA |
1.
2. C. Project Preparation Costs
Project budget is US$54,000.
No-objection of Health Sector Working Group.
[pic]
Definition of services covered by vouchers
Safe Delivery Vouchers: Each voucher will cost the customer between 1,000 Ushs (US$0.57) and 2,000 Ushs (US$1.14) per voucher and will cover delivery by a skilled birth attendant based on the Government of Uganda (GoU)/ Ministry of Health (MoH) Sexual and Reproductive Health Minimum Package. Services include antenatal care, safe delivery, emergency obstetric care and family planning. Antenatal care covered by the voucher scheme includes four visits as detailed below:
|Antenatal care covered by the voucher |
|Visit 1 (16 weeks) |Visit 2 (24-28 weeks) |Visit 3 (32-33 weeks) |Visit 4 (36-38 weeks) |
|Personal History |Review history of present |Review history of present |Review history of present |
|(social economic, type of work, |pregnancy (nausea, oedema of |pregnancy. |pregnancy. |
|age, smoking habits and alcohol |legs and feet, signs of anemia,|Record changes from last visit. |Medication review. |
|consumption etc.) |shortness of breath. Fetal |Medication review. |Review issues in past medical |
|Medical History (Diabetes, TB, |movements) |Smoking habits and alcohol |history. |
|Heart disease, hypertension, |Record any changes since last |consumption review. |Record any changes since last |
|epilepsy etc.) |visit. | |visit. |
|Obstetric History (history of |Medication review. |Identify high risk cases and the| |
|previous of pregnancies, |Review smoking habits and |need for specialized care or |Identify high risk cases and |
|multiple pregnancy, |alcohol intake. |referral. |the need for specialized care |
|miscarriages, stillbirths, | | |or referral. |
|premature labor, previous |Identify high risk cases and |Check on IBP | |
|caesarean section etc.) |the need for specialized care | |Check on IBP |
|Identify high risk cases and the|or referral. | | |
|need for specialized care or | | | |
|referral. |Check on IBP | | |
|Calculate EDD | | | |
|Advise on individual birth plan | | | |
|(IBP) | | | |
|Physical exam (fundal height in |Physical exam (fundal height in|Physical exam (fundal height in |Physical exam (fundal height in|
|cms, record on chart) |cms, record on chart) |cms, record on chart, edema, and|cms, edema) |
|Blood pressure / weight / height|Fetal heart present |fetal heart sounds) |Blood pressure |
|(BMI) |Fetal movements felt |Blood pressure ( look for signs |Fundal height in cms, record on|
|Vaginal exam plus PAP smear (if |Blood pressure |of pre-eclampsia) |chart.) |
|none in last 2yrs) |Weight |Fetal presentation. |Fetal presentation (cephalic, |
| |Urine test for protein |Fetal heart with Doppler |breech or multiple) |
| | |Fetal movements felt |Fetal heart with Doppler |
| | |Weight |Fetal movements felt |
| | | |Weight |
| | | |Vaginal exam if indicated. |
|Syphilis screenings, if positive|Recheck Hb if clinical signs of|Recheck Hb if signs of clinical |Recheck Hb if clinical signs of|
|treat. |anemia or low Hb on first |anemia. |anemia. |
|1st TT |visit. |2nd TT |Urine test for protein. |
|Hemoglobin (Hb), blood grouping,|Urine test for protein. |Urine test for protein. | |
| | | | |
|Urine test (dipstick) for | | | |
|protein and infection. | | | |
|HIV status | | | |
|Discuss PMTCT if HIV positive | | | |
|1st TT, iron, and folate |Iron and folate -check |Iron and folate -check |Check iron and folate |
| |compliance |compliance, |compliance. |
|Malaria prophylaxis, single dose|Discuss Malaria prevention. |Malaria prophylaxis, single dose|Advise on malaria prevention |
|(sulphadoxine 500mg, |(ITN) |(sulphadoxine 500mg, |(ITN) |
|pyrimethamine 25mg) | |pyrimethamine 25mg) | |
|Discuss safe sex during |Discuss safe sex, use of |Discuss IBP |Discuss IBP. |
|pregnancy, risk of HIV and STI. |condoms as in previous visit. |Repeat advice from previous |If over 41weeks go back to the |
|Use of condoms. |Repeat previous advice. |visit. |hospital. |
|Discuss when to stop breast | |Exclusive breast feeding of the |Breast feeding. |
|feeding previous child. | |infant. |Post natal contraception and |
|Nutrition during pregnancy. | | |when to come for post natal |
| | | |check and for 3rd TT. |
|Discuss danger signs (bleeding, |Discuss danger signs and when |Discuss danger signs, signs of |Discuss danger signs (including|
|abdominal pain) and who to call |to go to the hospital. |labor and when to go to the |ROM and meconium stained |
|or when to go to the hospital. | |hospital. |liquor), signs of labor and |
| | | |when to go to the hospital. |
|Fill in ANC Card |Fill in ANC card. |Fill in ANC Card. |Fill in ANC card. |
|One copy of card to be stay with| | | |
|the woman and be brought at each| | | |
|visit. | | | |
All cases of malaria and STDs diagnosed during pregnancy will be treated, as will conditions caused by pregnancy (i.e. hypertension and diabetes). Clients wishing to know their HIV status will be tested and, if positive, referred to a local centre providing PMTCT according to MoH guidelines. Emergency transport to a facility with C-section and blood transfusion capabilities will also be covered by the voucher.
|Obstetric Care Coverage |
|Normal Delivery |Skilled attendance at birth including intra partum care during labor and delivery by a mid-wife |
| |One postnatal visit at a clinic |
| |Health mother and baby check prior to discharge |
| |Contraception Counseling and provision of suitable contraceptives |
|Emergency Obstetric Care (as |Treatment of complications from labor including ventouse (vacuum) extraction where available |
|applicable) [14] |Emergency Transport from health centre to referral centre |
| |Blood Transfusions (pre- & post-delivery) |
| |Caesarean Section |
| |Induction and management of an inter-uterine death |
| |Destructive delivery of still-births |
| |Manual removal of retained placenta |
| |Prevention/ treatment of PPH |
| |Postnatal monitoring for up to 3 days |
| |One postnatal visit |
| |Contraception Counseling and provision of suitable contraceptives |
|Post Natal Coverage |
|1-4 weeks after delivery |Physical examination |
| |Blood pressure |
| |Weight |
| |Iron and folate if anaemic post delivery or large blood loss at delivery. |
| |3rd TT |
| |Contraceptive and child spacing advice |
| |Advice on breast feeding and when to wean the infant. |
STD Treatment Vouchers: STD treatment vouchers will be sold to customers at 1,500 USH (US$0.85) and will include diagnosis, investigation and treatment of acute sexually-transmitted diseases as per Uganda clinical guidelines issued by the MoH. Clinical guidelines for service providers will contain recommended treatment regimes, lab testing, and medications.
Voucher prices will be reviewed prior to the start of the expanded voucher scheme and ongoing during the scheme in order to ensure that target groups (the poorer segments of the population) are reached at the correct price.
Safe Delivery & STD Project Activities
|Start-up Activities |
|Activity |Description |
|1. Administrative Set-up |
|1.1 |Staffing |Dedicated project staff will be hired through a competitive process and staff will receive induction |
| | |training. |
|1.2 |Office preparation |Office space will be rented and renovated as needed to accommodate the project’s activities. The Mbarara |
| | |field office and existing space at MSIU and Microcare will be used to the greatest extent possible. |
|1.3 |IT set-up |Computers will be procured, installed and networked as required. |
|1.4 |Other procurement |All other procurement necessary for the project’s start-up will be carried out (i.e. vehicles). |
|2. Scheme Design |
|2.1 |Strategic planning |Detailed plans will be formulated for distribution, sales and BCC/marketing. |
|2.2 |Voucher services |Healthcare services covered by vouchers will be defined in detail during the start-up phase of the project.|
|2.3 |Voucher design |Careful attention will be given to voucher design during the start-up phase of the project. |
|2.4 |Guidelines and protocols |Clinical guidelines and protocols will be developed for Safe Delivery and treatment of STDs including |
| | |accreditation standards for health care facilities. Guidelines and protocols will be vetted by MSI’s |
| | |Medical Development Team, independent experts and the Peer Review Committee. |
|3. Service Provider Contracting |
|3.1 |Mapping |Existing data will be mined to map the location and capacity of potential voucher services providers. |
|3.2 |Selection |Facilities will be selected based on a number of criteria including management and clinical capacity, |
| | |quality of care, ability to conform to the scheme’s guidelines and protocols, cost effectiveness, |
| | |geographical distribution and not least low-income status of population served. |
|3.3 |Induction training |Selected SPs will receive training in both claims submission and the scheme’s guidelines and protocols. |
|3.4 |Accreditation |SPs will be accredited based on their ability to meet selection criteria and satisfactory completion of |
| | |induction training. |
|3.5 |Contracting |Legally binding Voucher Service Provider Contracts will be signed with accredited SPs. These will include |
| | |clear termination provisions in cases of inability to properly submit claims or comply with guidelines and |
| | |protocols. |
|4. Software Development |
|4.1 |Software redesign |Required software changes will be determined and software technical specifications developed. Consideration|
| | |will be given in this process to the need for data supporting both Quality Assurance and M & E activities. |
|4.2 |Programming |Claims management software will be reprogrammed to reflect changes detailed in the technical |
| | |specifications. |
|Ongoing Activities |
|Activity |Description |
|5. Coordination |
|5.1 |Liaison with MoH/GoU |Regular meetings will be held with relevant departments within MoH HQ, and at field level, with MoH |
| | |District Health Officers. |
|5.2 |Planning and management |The Strategic Oversight Team (SOT) will provide overall management of project activities: The SOT and Peer |
| | |Review Committee will each meet quarterly. |
|5.3 |Operational support |The Program Director and coordinators will provide day-to-day operational support for the scheme’s |
| | |activities. |
|5.4 |Reporting |Comprehensive quarterly and annual reports will be compiled detailing the project’s activities, |
| | |outputs/achievements, and lessons learned. |
|5.5 |Partnering |There are many complementary health care and related initiatives operating in Western Uganda. Partnerships|
| | |will be sought with these in order to maximize impact, avoid duplication of effort and realize cost |
| | |savings. |
|6. BCC/Marketing & Distribution |
|6.1 |Voucher production |An external vendor will be contracted to produce vouchers. |
|6.2 |BCC/Marketing |A comprehensive marketing strategy will be developed and marketing materials produced in a variety of media|
| | |including print and radio. |
|6.3 |Distribution |A distribution network will be developed within the catchment areas of SPs and vouchers will be |
| | |distributed. |
|7. Training |
|7.1 |Service Providers |SP training will emphasize guidelines and protocols and claims submission. Annual refresher training for |
| | |all SPs will be supplemented by additional instruction for low performing facilities. |
|7.2 |Distributors |Training for distributors will provide an overview of the voucher system, information about voucher |
| | |services and contact information for local SPs. |
|7.3 |Staff |Staff will be provided with ongoing training opportunities as needed to enhance the scheme’s capacity and |
| | |staff competencies. |
|8. Claims & Contract Management |
|8.1 |Vetting |Claims will be vetted both manually and automatically to detect problems and potential cases of fraud. |
| | |Vetting involves contact with SPs to resolve problematic claims. |
|8.2 |Data management |Claims will be entered into the system and tracked, reports will be generated and claims management |
| | |information will be analyzed. |
|8.3 |Payment processing |Payments will be processed on a monthly basis according to agreed treatment cost schedules with funds |
| | |remitted to SPs by bank transfer. Payment processing includes management of funds (banking and auditing) to|
| | |ensure timely SP remittances and transparent finances. |
|8.4 |Contract management |New contracts with SPs will be established and existing contracts terminated based on the scheme’s |
| | |requirements and SP performance. |
|8.5 |Records Management |The scheme will generate approximately 1,500,000 paper claims forms that will need to be retained for a |
| | |period of seven years. |
|9. Quality Assurance |
|9.1 |Clinical auditing |Regular clinical audits will be conducted to assess SPs for quality of care, capacity and conformity with |
| | |guidelines and protocols. |
|9.2 |Process review |Periodic review sessions will be held internally, and with a range of stakeholders, to assess the |
| | |efficiency and effectiveness of business processes including coordination, marketing and distribution, |
| | |training and claims management. |
|9.3 |Financial auditing |Voucher scheme finances will be treated as a separate project within the context of Microcare and MSIU’s |
| | |normal financial audit regimes. |
|10. Monitoring & Evaluation |
|10.1 |Ongoing project monitoring |Ongoing project monitoring support will be provided by external organizations to ensure the project meets |
| |support |its intended objectives |
|10.2 |Baseline study |A baseline study will be produced at the start of the four-year funding cycle |
|10.3 |Annual evaluations |Annual project evaluations will be conducted and utilized to modify and enhance project approaches and |
| | |outputs. |
|10.4 |End-term evaluation |An end-term evaluation will be produced at the conclusion of the four-year funding cycle. |
Example of a claims processing form
Date…/……/…… Time: ………………
Personal Information:
Client Partner Visit type: Consultation 1st follow up 2nd follow up
1. Patient Name: ……………………………………… 2. Age ………… 3. Gender M F
4. Village: ……………………………5. County: …………………………6. Sub-county…………………..
7. Medical Information: (Section to be filled by Doctor) Name:
|Syndrome |Clinical Examination |
|URETHRAL DISCHARGE |OPTHALMIA NEONATORUM | |
|GENITAL ULCER |ACUTE SCROTAL SWELLING | |
|ABNORMAL VAGINAL DISCHARGE |INGUINAL BUBO | |
|PID | | |
Diagnosis ...………………………………………………………………………….
……………………………………………………………………………
……………………………………………………………………………
8. Investigations:
|Service |Result |Amount |
| | | |
| | | |
| | | |
9. Drugs:
|Prescribed Drugs |Route |Freq. |No. of Days |Total |Amount |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
10. Consultation fees and other charges:
|Services |Details |Amount |
| | | |
| | | |
Grand Total
11. Patient Status: Cured Not Cured Referred Hospital/Clinic name ……………………….
12. Next visit date: ………/………/………. 13. HIV status: N/A Yes Count …………..
14. MEMBER'S DECLARATION / MEDICAL WAIVER: I hereby declare the above stated to be true and in accordance with the medical scheme rules and allow the medical department of MSIU access to the above information.
Sign: ………………………………………………………. Date: ……………………………………..
15. DOCTOR'S DECLARATION: I certify that the above amount is in accordance with my specified treatment and to the best of my knowledge and belief the claim is approved for payment/reimbursement
Sign: ………………………………………………………. Date: ……………………………………..
16. PHARMACIST DECLARATION: I certify that the above drugs have been dispensed according to the doctor’s written prescription
Sign: ………………………………………………………. Date: ……………………………………..
Thumb Print: Voucher sticker: Clinic Stamp:
NOTE: - ALL FIELDS MUST BE FILLED FOR PAYMENT OF CLAIMS PATIENT’S THUMB PRINT AND VOUCHER STICKER TO BE FIXED
- MSIU. WILL NOT PAY CHEMISTS BILLS UNLESS THEY ARE RELATED TO A DOCTORS PRESCRIPTIONSFROM AN APPROVED SERVICE PROVIDER
Map showing the main project site in the country
-----------------------
[1] Based on the exchange rate of April 24, 2007: 1EUR=1.35812US$
[2] Steadman, July 2005, STI Treatment Voucher System, Survey on Target Populations
[3] Data on delivery in private for profit institutions is not available, but not expected to raise the percentage of births attended by trained health workers significantly.
[4] MOH, 2000, Uganda Demographic and Health Survey
[5] One of the problems of treating patients with sexually transmitted diseases is fear of stigmatization in public health facilities. Such stigmatization does not exist at private medical facilities, because their earnings depend on attracting patients, including those with STDs.
[6] Islam, Karmul; Gerdtham, Ulf-G; The cost of maternal-newborn illnesses and mortality; WHO; 2006
[7] Incremental benefit means the portion of the benefits of reduction of low birth weight cases (US$ 97.50) that are above the benefits of productivity loss (US$ 54.91). The result (US$ 42.59) can safely be attributed to benefits not explained by productivity loss.
[8] Based on Demographic Health Survey and Islam, Gerdtham
[9] Data for maternal mortality based on World Health Report; WHO 2003, other data are conservative estimates.
[10] Provided that IFC Administration Agreement is extended from its current July 30, 2011 deadline
[11] Marie Stopes International is a London-based charitable organization with local branches in 39 countries. MSI UK is responsible for establishing and managing family planning centers, nursing homes and referral centers in the UK and other developed countries like Australia and Austria.
[12] KfW’s contribution shown in Euros (¬ ) will be fixed in US$ at the time of disbursement
[13] Final confirmation from the lawyer as to whether a combination of Grant Agreen shown in Euros (€) will be fixed in US$ at the time of disbursement
[14] Final confirmation from the lawyer as to whether a combination of Grant Agreement/MOU is more appropriate than a consulting contract based on General Service Department (GSD) standard terms and conditions is pending. However given the experience of the Uganda Small Towns project, the lawyer suggested that a Grant Agreement/MOU solution might be the most appropriate.
[15] The Emergency Obstetric Care package to be offered as part of the expansion program is currently under review. The details listed here are therefore subject to change.
-----------------------
Strategic Oversight Team
Service Provider Mgt, QA & Supervision
Contracting
Claims Processing
Finance/ Admin
Quality Assurance (QA)
Marketing/ Distribution
Training
Sales
Microcare
Service Provider Coordinator
MSIU Project Coordinator
Program
Director
49293
7. Documentation of interventions performed
8. Verification / audit report
6. Disbursement
4. Advance
5. Documentation
3. Disbursement request incl. projection and performance bond
1. Disbursement request incl. projection interventions to be performed
2. Advance
GPOBA
KfW
VMU
Service Providers
Verifier / Auditor
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