New Approaches for Reproductive health Initiatives (NARI) OBA Voucher Scheme was a one year project that was implemented in 10 Union Councils of 02 Talukas i.e. Dadu and Johi and benefited 0.5 million population of District Dadu 10 Union Councils of with the collaboration of District Health Department. HANDS introduced an innovative model of Output Based Aid (OBA) Voucher Scheme. The project initiated from 1st November 2008 and concluded on 30th October 2009. The initiative tried to create demand-side supply by implementing the OBA voucher approach for complicated pregnancies targeting underserved and marginalized women. The project is funded by USAID under TACMIL (Technical Assistance for Capacity Building of Midwives, Information and
The project initiated in November 2008 with the conduction of baseline research to analyze the state of public and private sector health facilities and health providers with reference to care and referrals regarding Emergency Obstetric and Neonatal Care (EMoNC) services. HANDS assessed total number of 31 public health care facilities including 20 Basic Health Units, 01 Rural Health Centers, 01Taluka Head Quarters, 01 District Head Quarter Hospitals and 07 Dispensaries. The household survey was also conducted to assess the knowledge, attitude and practices of 3 delays and complications of pregnancy.
To assess the knowledge attitude and practices of the child bearing women the household survey was conducted using “Cluster sampling” method. The 2 Talukas (Dadu and Johi ) were the universe of the study. In addition 60 clusters were defined (30 clusters from taluka Dadu and 30 from Taluka Johi). Seven household interviews were conducted from each cluster amounting to a total sample of 420 households. Four referral health care facilities were also included that is 01 DHQ (govt. health care facility) and 3 private health care facilities were assessed for their clientele and services provided under NARI project.. Later data validation, data feeding, analyses were done.
A monitoring strategy was developed including flow of Management Information System (MIS) tools. 1300 NARI Referral Forms (OBA Voucher) for complicated pregnancies & 700 for neonates designed, pre tested and printed . These were placed at all the first level care public sector facilities. Each referral form is having few information about referred women or neonate with 19 choices of dangerous / high risk signs / symptoms to be marked by health care provider for complicated pregnancy and neonate. HANDS clinical monitoring coordinator was responsible to validate the rational of admission of the patients on the basis of referral form and clinical examination. HANDS clinical coordinator was authorized not to allow or entertain all irrational and unethical admissions. 14000 (140 pads x 100 hospital case sheets in each pad) Patients Case Sheets for complicated pregnancies and Neonate were designed, pre tested and printed. These were used to keep the record of the patients during management at selected referral facilities .A Web based application was also developed for day to day data feeding of admitted cases and to monitor the progress of the project
A comprehensive communication strategy was designed with the focus to introduce OBA Voucher Scheme & its mechanism, disseminate danger signs of pregnancy and to promote public/private health facilities among communities for their maximum utilization. The BCC campaign was of 6 months and targeted 85000 married couples about complications of pregnancy. 10,000 Posters and 75,000 Leaflets, designed, composed, pretested, Printed and disseminated with health education messages on dangerous / high risk signs and symptoms of complicated pregnancies and neonates. 4000 leaflets per Union Council Distributed. Wall painting of NARI messages were done at 80 places of Taluka Dadu & Johi. Four animated movies (2 for married / pregnant women and 2 for husbands) of 50 seconds each were developed to introduce NARI referral voucher and danger /high risk sign and symptoms during pregnancies through 14 local cable networks
Orientation meetings with councilors, staff of District Government hospital /private secondary care health facilities at Dadu were held. Dissemination seminar organized in Dadu for awareness raising of project, participated by 150 stakeholders. All the public health facilities were briefed about the project and their role in referring to Private and DHQ Hospital. Health Care Providers (HCPs) at public health facilities trained in identifying the clients with complicated pregnancies/ danger signs.
Several trainings, mass mobilization events, coordination meetings organized. Notable, literary persons, Social Workers, Media Personnel, Officers of Line Departments & Elected Representatives of the area visited the Public and private referral facilities to monitor the process of project implementation
The total number of women and neonates benefited at the referral health facilities were 597 (with 446 women and 151 neonates). Out of 446 women 122 were referred/ managed at public facility and 324 at the private health facility. Similarly, out of 151 cases of neonates with complications/danger signs, 46 were referred/ managed at public health facility and 105 at private health care facilities.
Total 306 women delivered at referral health facilities, out of which 108 were delivered at public health care facilities and 198 at private health care facilities. Among the total 306 delivered women 81(26%) were assisted vaginal deliveries (forceps/ vacuum with episiotomy) 225 (73%) caesarian sections. The larger percentage of Caesarian section was probably due to the fact that these were already complicated cases and normal delivery was not possible and was the main reason for referral.
The mean age of the benefitted women was 28 years and benefitted neonates was 2.8 days at the time of treatment. The mean number of conception among benefited population was 4.3 while mean number of alive children was 3.5. Majority (80%) of the benefitted population belong to poor population having the Kaccha and Kacha pucca household. Only 20% of them had Pucca household structure.
District Kashmore, Jacobabad and Thatta, Sindh
HANDS NARI (New Approach for RH Initiatives) was initiated on 22 Sep 2010 in three flood affected districts of Sindh, ie Kashmore, Jacobabad and Thatta.
The project was funded by David and Lucille Packard Foundation
The proposed OBA Voucher scheme is founded on a partnership between the service provider (Public/Private health facilities) and a voucher Management Agency (VMA) i.e. HANDS. The VMA is responsible to administer specific aspects of the model such as motivation of the IDPs to utilize selected health services; identify voucher recipients based on developed eligibility criteria. Public and Private Service facilities as the service provider is responsible to ensure the services HANDS would redeem the cost against voucher for the pre determined service to the provider after verification from Public and Private Service facilities to sustain its services.
Output Based Aid (OBA) Voucher Scheme
The initiative implemented a demand-side supply through Output Based Aid (OBA) voucher approach in Districts Thatta, Kashmore and Jacobabad for complicated pregnancies targeting underserved and marginalized women. This subsidy will directly benefit the health care consumer (client) in the form of a voucher that will be redeemed by receiving EMOC – RH services from the selected public / Private health facilities.
The project initiated in September 2010 with formation of 22 medical teams that were to visit IDP camps in there flood affected districts of Sindh ie Kashmore, Jacobabad and Thatta. These medical teams performed the following
- Enlisted pregnant women in medical camps
- Performed ante-natal checkups
- Counseled pregnant women on nutrition and danger signs of pregnancy
- Distributed Vouchers to pregnant women that were to be utilized for services in nominated HCFs
Project staff comprising of a project manager and five associates were recruited in each district. Partnerships was formed with public health facilities. HANDS oriented district management and Civil Society Organizations about the project especially “Voucher Scheme”. The health facilities (BHU, RHC THQ/DHQ) were also briefed about the project. HANDS medical teams selected
3 Public Sector and 6 Private facilities.
These selected Private health providers were briefed and MoU were signed between HANDS and private health providers. They provided health care facility to the referred cases and. THQ/DHQ/Private secondary care facility received clients, verified eligibility criteria for OBA, ensured health care services as per requirements, called VMA (HANDS) for verification and reimbursement
A communication strategy was designed with the focus to introduce OBA Voucher Scheme & its mechanism, disseminate danger signs of pregnancy and to promote public/private health facilities among communities for their maximum utilization. Besides orienting the government officials and local notables about the OBA Scheme, 3000 Posters and 3000 Leaflets were printed and disseminated with health education messages on dangerous / high risk signs and symptoms of complicated pregnancies and neonates. A media campaign to disseminate NARI Project was launched in which daily hourly messages were aired from three FM radio stations of Kashmore, Jacobabad and Thatta.
Monitoring strategy included flow of Management Information System (MIS) tools. 3000 NARI Referral Forms (OBA Voucher) for pregnancies & 1000 for neonates were printed . These were handed over to NARI Medical teams for distribution in IDP Camps and later in affected villages . Each referral form is having few information about referred women or neonate with 19 choices of dangerous / high risk signs / symptoms to be marked by health care provider for complicated pregnancy and neonate while being examined in IDP Camps / Affected Village. HANDS clinical monitoring coordinator was responsible to validate the rational of admission of the patients on the basis of referral form and clinical examination. HANDS clinical coordinator was authorized not to allow or entertain all irrational and unethical admissions. 20000 (200 pads x 100 hospital case sheets in each pad) Patients Case Sheets for complicated pregnancies and Neonate were printed. A record of the patients during management at selected referral facilities was immaculately maintained.
A total of 2076 women and neonates in three flood affected districts benefited from HANDS NARI Project. Out of these 1717 were women 359 neonates. Amongst these, 673 were managed in facilities at Jacobabad, 567 at Kashmore and 836 at Thatta. Among the total 2076 delivered women 1127 (66%) were normal vaginal deliveries and 590 (33%) were caesarian sections.