1. MCH Voucher Scheme and
Hospital Equity Fund : An Update
Financing Schemes : Health System Strengthening
Dissemination on Implementation of Health Systems Strengthening in (20) Townships
MOH Meeting Room, Nay Pyi Taw, Myanmar, 6th August 2012

2.  Financial barriers is a fundamental problem in
improving access for mothers and children
during health systems assessments
 HSS funds have been identified to remove
these financial barriers
 In Yedarshay, the concept of “Maternal and
Child Health Voucher Scheme” (MVS) has been
developed to improve access by the poor to life
saving
pregnancy
treatment services
related
referral
and

3.  All poor pregnant women and the newly
born infants especially those residing in
hard-to-reach areas
 Health care providers as regards rural and
urban

4.  (4) AN Care
 Normal delivery with SBA at home or at health
center
 Management of complications
 Food cost, lodging cost, travel cost and direct
medical care cost covered by Hospital Equity
Fund
 (1) PN care

5. Summary: budget for MCH Voucher Scheme
Point of
service
delivery
4 ANC +PNC
For
pregnant
women
For
providers
Delivery
For
pregnant
women
Total
For
providers
Services at
home
1,000 k
4,000 k
+1,500 k
5,000 k
11,000 k
22,500 k
Service at
health
facilities
8,000 k
4,000 k
10,000 k
10,000 k
32,000 k

6. Estimated service uptake
according to the revised plan
ANC with SBA
Baseline
Revised plan
Delivery with
SBA
73%
51%
93% - 100%
59% - 67%

7. V
V
V
Outreach
Management
agency
V
Multiple
voucher
distributors
Administrative burden
V
V
V
Village
V
V
V
V
V
V
Over utilization
Yedashe
Township
Hospital V
V
Health
facilities
MoH

8. Financial management process

9. Healthcare providers
Health facilities
• Register pregnant women.
• Provide MCH services stated in the benefit
package to pregnant women with the
vouchers.
• Submit the providing services forms (P1),
summary of the service provision forms (P2),
and vouchers to management agency for
reimbursement on a monthly basis.

10. Management agency
M2i
Distributors
Distributors
Monthly
V1
i
• Verify the documents submitted by voucher
distributors and healthcare providers (V1 vs
P1) .
• Disburse the expenditures to distributors and
healthcare providers without delays (2
weeks), along with the summary of the
disbursement forms (M1).
• Report the activities and financial statement
Monthly
to the MoH on a quarterly basis (M2).
• Performance evaluation
Management
Agency
Not more than 2
weeks
P1
i
P2
i
M1
i
Health facilities

11. Monitoring and Evaluation
Levels
Process
Outputs/outcomes
Immediate
Intermediate
Final
Health
Economics
Population
• Number of
voucher
distribution
• Awareness
• Attitude
• Trust
• Utilisation of
MCH services
• Proportion of
voucher
reimbursement
• Maternal/
Infant
morbidity &
mortality
• Value for
money
Providers
• Satisfaction
• Participation
• Adherence to
the protocol
• Awareness
• Attitude
• Trust
• Quantity &
quality of
services
provided
• Capacity
building
-
• Financial
space
Household/
individual
• Satisfaction
• Awareness
• Attitude
• Trust
• Knowledge
• Utilisation of
MCH services
• High risk
pregnancies
received
proper care
• Reduction of
household
expenditures
+ Program performance evaluation

12. What is the high priority measures?
• Monitoring for service utilization
– Number of vouchers distributed
– Number of voucher utilization
Source of data: from VD1 and P1 form
Source of data: from VD1 and P1 form
• Adherence to the protocol
– Completeness, average and range of
disbursement process
Source of data: from P1 and M1 form, monitor q 3-6 months if possible
Source of data: from P1 and M1 form, monitor q 3-6 months if possible

13. • Cost of programme implementation
– Reimbursement cost of providing ANC at home/health
facility
– Reimbursement cost of providing delivery at home/health
facility
– Reimbursement cost of providing PNC at home/health
facility
Source of data: from reimbursement records
Source of data: from reimbursement records

14. What is the priority measures?
• Costs of programme implementation
–
–
–
–
–
–
Costs of voucher production
Costs of distribution of voucher
Costs of voucher reimbursement system
Costs of administrative tasks
Costs of communication campaigns
Costs of human resource training
Source of data: from management agency
Source of data: from management agency

15. What is the priority measures?
• Costs of programme implementation (HEF)
– Reimbursement cost of complication management
– Reimbursement cost of providing caesarean section
including medicines
– Reimbursement cost of transportation to referral facility
Source of data: from reimbursement records
Source of data: from reimbursement records

16. Performance evaluation
Indicators
Sources of data
Voucher distribution/ utilization rate (also by services)
V1 and P1
Payment by items
(Medical cost, incentive cost, administration cost)
M2
Time to completed disbursement process
( Completeness, average and range)
P1 and M1
Reimbursement of the provider requests
(% full amount, gap)
P2 and M1
Frequency of internal account audits
(6 months)
MoH staff audit
Satisfaction of the financial process?
Survey (Pregnant women,
distributors and healthcare
providers)

17. Hospital Equity Fund (or) Patient
Referral Fund for poor mothers and
children
GAVI HSS

18. Health systems assessments conducted in Myanmar
between 2009 and 2011 in 20 HSS Townships
• Financial barriers to access- have been identified
as a fundamental problem in improving access
for mothers and children
• HSS funds have been identified in order to
assisting with removing these financial barriers.
• In the Township of Lewe, the concept of a
“Patient Referral Fund” has been put forward in
the CTHP to improve access by the poor to life
saving referral and treatment services at the
Township Hospital.

19. HEF
Objectives:
• To enhance access by the poor mothers and children
to hospital based services, through provision of
targeted medical allowance for emergency transport
and emergency and life saving procedures at the
Township Hospital.
Expected Outcomes/Output
• With this fund support, could save the lives of poor
mothers and children,
– who are difficult to access to hospital (physically or
economically)
– by getting timely referral and treatment,

20. Beneficiaries
• All emergency patients (mothers and children
under 5 pre identified as poor) with life
threatening conditions (this includes
classifications of mothers or children as being at
“high risk” of a life threatening condition).
• Mothers and pregnant women and children 0 –
5 of a specified income level (post identification
for eligibility) at entrance of hospital

21. Benefits Package
• Emergency procedures (such as cesarean section
and other life saving procedure)
• Management of Complicated delivery (eclampsia,
obstructed delivery, APH and PPH and abortion
related complications)
• Other life saving emergencies (e.g. RTA and snake
bites and others)
• Management of Child hood acute illness
(e.g. peummonia, diarhhoea, dengue and malaria
or other acute condition)

22. Details of Benefits
• Reimbursement of medicines and related costs
(procedures) and transport and food costs
• 5 – 10 days stay in hospital with one attendant
• Total reimbursement not exceeding 100,000
kyats for the whole benefit package
• The option should be considered for forwarding
part of the referral fund to selected RHC for
emergency transport, to be overseen by the RHC
supervisory committee.

23. HEF Fund Holders
According to the guideline flow of this Hospital Equity
Fund will be supervised by budgetary sub-committee
under the township health committee.
The Budgetary sub-committee is organized by –
• Local well wisher who involve in the township health
committee
- Chairman
• Gazette officer from the District/Township Health
Department
- Member (1)
• Local well wisher
- Member (2)
• District/Township Medical Officer - Secretary
• Accountant

24. Assessment of Eligibility for Benefits
• Eligibility for benefits should be based on pre
identification of income/asset status.
• This should be accessed through
– Using social mapping methods,
– community leaders, local authorities and elders
should assess and select the village areas and
households with the “most poor status.”
– Through package tour by group of BHS for
identification of poor mothers and children

25. Reporting and Auditing
• Support can be provided through the Hospital Supervisory
Committee and Township Auditors Office for Reporting.
A Patient Referral Fund (PRF) Report form should be completed
detailing:
• Name and address of beneficiary
• Medical Condition
• Benefits provided (Medicines, Food and Transport,
procedures)
• Attachment of pre identification questionnaire
• Signatures of patient/family of patient and of Chair of
Hospital Supervisory Committee or other non medical
member.

26. Estimated Budget for one patient:
• Transportation cost for emergency referral of patient = 35,000 Ks
• Treatment cost (Drug cost + other treatment cost)
= 40,000 Ks
• Perdiem – 3,500 Ks x 8 days (during the hospital stay) = 28,000 Ks
103,000 Ks
• For 1 township = (6-7) patients/mth x 12 mths = 80 patients for
one year
• For 1 township = 103,000 Ks/pt x 80 patients = 8,240,000 Ks

27. HEF funds distributed to 20 townships
in May 2012
Budget used status as of July 2012
• Townships that have not started using HEF= 5
• Townships that have used HEF
= 15

28. Kawt Hmu Township, May 2012
SN Patient's Name
Age/ Sex
Treatment
Cost
1
Daw Kyin Mya,
APH
46, F
Em. LSCS
Drug costTA –
DA (pt+1) -2x2000x7D=
Total -
2
Su Su Hlaing,
Breech
presentation
24, F
Em. LSCS
Drug costDA (pt+1) -2x2000x7D
Total -
31625
28000
59625
3
Ma Myint Thein
Hydraminos,
baby congenital
abn
31, F
Em. LSCS
Drug costTA –
DA (pt+1) -2x2000x7D
Total -
20900
30000
28000
78900
4
Nu Nu Win
30, F
Normal
labour
Drug costDA (pt+1) -2x2000x4D
Total -
6725
16000
22725
Total
(kyats)
31625
35000
28000
94625
255,875

29. Kawt Hmu Township, May 2012
SN Patient's Name
Age/ Sex
Treatment
Cost
1
Pyae Pyae Aung
4, F
Acute GE
Drug costDA (pt) -1x2000x3D=
Total -
1525
6000
7525
2
Phyo Ainga
4 mth, F
Acute GE
Drug costDA (pt+1) -2x2000x3D
Total -
4300
12000
16300
3
Saint San Yae
3 1/2, F
Acute Viral
infection
Drug costDA (pt+1) -2x2000x3D
Total -
2100
12000
14100
Total
Grand Total
(kyats)
37,925
293,800

30. Ngaputaw Township, May 2012
SN Patient's Name
1
Naw Aye Thaw
2
Ma Khin Hmwe
Grand
Total
Age/ Sex
,F
,F
Treatment
Cost
(kyats)
Normal
Labour
Drug costDA (pt) -2x3000x7D=
Total -
46925
42000
88925
Normal
Labour
Drug cost-
55925
144850

31. HEF Expenditure for May
S
N
Townships
No of
Patient
DA
TA
Drug Cost
Total Cost
(kyats)
1.Kawthmu
7
130000
2.Ngaputaw
2
42000
Total
172000
65000
293350
102850
65000
98350
144850
201200
438200
Unit Cost: 48,689

32. HEF Expenditure for June
S
N
Townships
No of
Patient
DA
TA
Drug Cost
Total Cost
(kyats)
1Bamaw
5
147000
115000
219500
481500
2Shwegu
7
196000
64000
173000
433000
3Hlaingbwe
4Mudon
4
6
66500
133000
69000
210000
166445
157000
301945
500000
5Kyaingtong
6NyaungShwe
3
3
2
84000
88885
70000
66500
87250
24000
67400
241250
179385
67400
2
6
1
3
5
68000
126000
0
84000
20000
12000
0
105000
62950
138000
57405
111000
95860
150950
276000
57405
300000
95860
47
993,385
1,359,810
3,084,695
7Hsipaw
8Kawthmu
9Htilin
10YeOo
11Myeik
12Ngaputaw
Total
731,500
Unit Cost: 65,632

33. HEF Expenditure for July
S
N
Townships
1Bamaw
2Shwegu
3Demawsoe
4Hlaingbwe
5Hakha
6Thaton
7Mudon
8Kyaingtong
9Hsipaw
10Kawthmu
11Htilin
12YaeOo
13Myeik
14Ngaputaw
Total
No of
Patient
DA
TA
Drug Cost
Total Cost
12
12
1
3
3
2
7
252,000
291,000
28,000
59,500
80,500
58,000
136,500
247,000
165,000
10,000
50,000
76,000
45,000
175,000
498,800
111,000
37,000
113,600
128,500
128,500
160,220
(kyats)
997,800
567,000
75,000
223,100
285,000
231,500
471,720
3
2
8
1
2
10
10,500
52,000
126,000
5,000
45,000
160,000
38,500
20,000
1,152,500
55,000
32,700
29,250
232,000
44,394
74,000
190,095
48,200
126,250
518,000
44,394
167,500
210,095
1,780,059
3,965,559
66
1,033,000
Unit Cost:60,084

34. HEF Expenditure Total For 3 months
SN
Townships
No of
Patient
DA
TA
Drug Cost
Total Cost
(kyats)
1Bamaw
2Shwegu
3Demawsoe
4Hlaingbwe
5Hakha
6Thaton
7Mudon
17
19
1
7
3
2
13
399,000
487,000
28,000
126,000
80,500
58,000
269,500
362,000
229,000
10,000
119,000
76,000
45,000
385,000
718,300
284,000
37,000
280,045
128,500
128,500
317,220
1,479,300
1,000,000
75,000
525,045
285,000
231,500
971,720
3
3
84,000
88,885
70,000
66,500
87,250
24,000
241,250
179,385
5
10,500
5,000
100,100
115,600
11Kawthmu
12Htilin
11
14
250,000
252,000
130,000
172,000
190,550
370,000
570,550
794,000
13YaeOo
14Myeik
15Ngaputaw
2
5
17
0
122,500
62,000
0
160,000
0
101,799
185,000
388,805
101,799
467,500
450,805
122
2,317,885
1,829,500
3,341,069
7,488,454
8Kyaingtong
9NyaungShwe
10Hsipaw
Total

35. Challenges
• Identification of poor (pre assessment)
• Identification of poor (post assessment- easy for 25 and 50 bedded hospital,
- difficult for 100 & 200 bedded hospitals
-management by OB Gyn
• Poor but need elective LSCS
• Poor in non emergency???
• Sustainability

36. Thank You