Voucher agency

Partners may make different types of contributions. Some can provide services, others technical assistance some can distribute vouchers, others can lobby donors. It is vital to keep an eye out for institutions that could perform the crucial voucher agency role. 

Organization capable of serving as voucher agency exists. 

No institution capable of performing voucher agency role ... 

Lack of Institutional Capacity to Perform the Voucher Agency Role... 

Voucher schemes require transport and mm mi mirations networks developed enough to ensure the reliable distribution of vouchers and the timely exchange of information between the voucher agency and other organizations involved. A detailed discussion appears in chapter 5. 

The voucher agency can be a public sector institution, a private sector institution, or a parastatal organization, which has more independence and autonomy than traditional government departments. Whichever type of institution is chosen, the voucher agency must have four attributes ... 

The voucher agency must be neutral. It should not have links to any potential service providers, as such links could create conflict of interest. Thus, if ministry of health clinics are participating in the scheme as providers, it may not be appropriate for the ministry of health to serve as the voucher agency. Other public sector institutions, such as the ministry of finance, could be sufficiently independent of service providers. 

The voucher agency must have the appropriate range of skills and experience. Needed skills include the ability to negotiate and contract with service providers and the ability to monitor performance of those contracts, including any quality specifications they may stipulate. General account-... 

Write the recipient s name on the voucher and ask the provider to confirm it by asking to see a photo identification card. To ensure that the provider checks the recipient s identification, the provider can be required to fill in the number of the identification card, which the voucher agency can check against a register kept at the time the voucher is distributed. This process may be costly, and many poor people may not have personal identification. 

La Clinica, the voucher agency and provider of some services in a voucher scheme for migrant farm workers in Wisconsin, has a fixed third-party provider reimbursement schedule (box table 5-2). 

Willingness and ability to send samples to laboratories and patient records to the voucher agency... 

The cervical cancer screening program in El Salvador needed to contract with a laboratory to provide cytology results, but none of the laboratories tested passed the voucher agency s proficiency test. The lack of a provider encouraged a few professionals who were skilled at reading Pap smears to form a laboratory, which was subsequently contracted by the voucher agency. 

The value of the voucher is the amount the provider receives upon returning the voucher to the voucher agency. The simplest mechanism is one in which providers agree in advance to a fixed value for the voucher and all providers receive the same amount. This method is used if a benchmark price is used to select providers. 

Sometimes it can help to create a voucher with multiple tear-off or cut-off sections, in which one part of the voucher remains with the bearer, while other parts are returned to the voucher agency or sent to a laboratory with the specimens (box 5-6). It can also be useful to leave a space in the voucher for the patient s signature, to ensure that patients actually receive the health service they were supposed to have received. This signature can be compared with one obtained at the time the voucher is distributed. Doing so can help monitor transfer of vouchers to indirect recipients and detect fraud by providers. 

GinecoBONO, the voucher used in the cervical cancer program in Nicaragua, is sequentially numbered, with the expiration date stamped on top and the services offered clearly stated both inside and outside the packaging, which is a packet or booklet. One part of the voucher, which includes a space to write the appointment for the second visit (to collect test results), is retained by the patient. The other part of the voucher is retained by the clinic. The patient is asked to sign this part of the voucher, which is then returned to the voucher agency as proof that service was rendered. 

In the Taiwan (China) female contraception program, the voucher consisted of three detachable parts, each of which served a different purpose. The first part remained with the field worker as a record of distribution, the second and third parts were given to the patient, who handed them over to the physician. The physician held on to the third part as a proof of services delivered. He or she sent the second part by registered mail to the county nurse, who forwarded it to the voucher agency. This part of the vouchers was used for reimbursement of services as well as evaluation and monitoring purposes. 

Voucher schemes require reliable communications—between the voucher agency and voucher distributors and between the voucher agency and service providers. The voucher agency needs to be able to distribute the vouchers. Providers need to be able to return them, along with any information required, to the voucher agency. Patients sometimes need to be transported to specialist care providers. The logistics involved in organizing reliable transport and communications can be complex (box 5-7). To ensure that they work properly, they should be pilot tested. 

If providers are required to send samples to a central laboratory, systems to transport the samples need to be established, along with reliable ways to ensure that providers, patients, and usually the voucher agency receive the results. Producing double (or triple) copies of the results can help. 

Vouchers can be distributed by the voucher agency, by an external agency contracted by the voucher agency, or by providers. In most cases, vouchers can be handed directly to beneficiaries. It is also possible to make the vouchers available at various dispensing points (such as municipalities), where beneficiaries pick them up. This strategy can significantly lower costs. Box 5-8 describes a scheme in which community leaders were responsible for voucher distribution. 

It is important to keep track of whom the vouchers have been given to. The voucher agency should record the serial numbers of the vouchers given to distributors. These simple measures facilitate evaluation of the efficacy of the voucher distribution strategy. They also provide a check on counterfeiting and prevent distribution of vouchers at the point of service delivery. 

Health promoters from the voucher agency and private clinic nurses distribute the vouchers. Service providers organize and pay for distribution, which is coordinated and supervised by the voucher agency. 

Medical records, Pap smears, and laboratory results are sent to the voucher agency in the capital by planes, buses, a courier service, and some of the clinics own vehicles. The cost is shared by service providers and the voucher agency (on behalf of the subsidy provider). 

Community health workers follow up on patients with high-grade lesions who fail to return to the clinic for their results. The workers visit the women and advise them that they need treatment. If this fails, a promoter from the voucher agency is sent. If necessary, the health promoter provides the woman with the money required for transport to the clinic. 

In the simplest cases, service providers bring or mail in the vouchers and the voucher agency calculates the amount owed, writes a check, has the provider sign a receipt, and records the numbers of the vouchers that have been returned. If a computerized information system is in place, it is not difficult to have it automatically generate receipts for each provider, with... 

As a general rule, the voucher agency should receive a copy of all forms. Service providers will probably wish to keep a copy of the form for their records. Sometimes diagnostic service providers will require copies of at least parts of the clinic record. Multiple copies of forms can be produced cheaply using NCR (no carbon required) paper that prints through to the sheet below with the pressure of a pen. 

Has a set of rules been drawn up to define who receives the vouchers, what the voucher entitles its bearer to, what the bearer must pay to the provider to use the voucher (if anything), who can participate in the scheme as service providers (and under what conditions), and what each provider will receive in payment from the voucher agency (and how payment is to be determined) ... 

If the number of service providers is limited—either because of the administrative costs involved or because of the desire to achieve potential economies of scale—some degree of competition can be retained by awarding the contract (or contracts) by public tender. Tendering for service providers allows the voucher agency to make a selection based on price and quality. In drawing up the announcement, it is essential to make the... 

Price is one of the key points to be negotiated in a competitive voucher scheme. The voucher agency wants to keep the price as low as possible... 

Minimum standards of care and patient management protocols should also be agreed on at this stage. Evidence-based management protocols— selected by experts in the voucher agency or by external consultants— should be the preferred choice. Some health service providers may not be up to date on these issues. 

It is important to establish and agree on ownership of laboratory specimens, X rays, and medical records on who is to store them and for how long and on who may have access to them in the future. It may be desirable for the voucher agency to retain intellectual property rights of all data for all studies and publications. Patient confidentiality must be respected at all times, but the voucher agency may want to request access to medical records for supervision or study purposes. If the voucher scheme incorporates a research component involving human subjects, it is essential to obtain approval from the appropriate bodies and, if necessary, informed consent from the patients. 

Health care providers may not be accustomed to working under written contracts and may find the process threatening. It is therefore important to clarify that the main purpose of contracts is to set out and agree upon a set of rules that suit both parties. A contract should set out not only the provider s duties and commitments but also the purchaser s. For instance, the voucher agency may commit itself to train the provider s staff, to reimburse providers in a timely manner, to follow up specific cases, and so forth. 

All new programs involve a training component. In the case of voucher schemes, training can be needed for voucher agency staff, for contracted service providers, and for voucher distributors. What are the training needs at each level ... 

The acceptance. The purchaser (the voucher agency) agrees to pay the provider according to the terms in the contract. The acceptance may also stipulate when the agreement comes into effect. The acceptance is signed by the voucher agency. 

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