Cash and vouchers can improve health outcomes – but you must understand the challenges first
In this blog, we focus on the challenges related to achieving health-related outcomes through Cash and Voucher Assistance (CVA) in humanitarian response. Using CVA to advance health outcomes is different from using CVA in other contexts and challenges practitioners to work in new ways. We discuss the objectives of the health sector, the barriers faced, and then we show how CVA can help overcome particular barriers to support these goals. We conclude with some practical advice on avoiding and mitigating these common issues to enable an effective response. Fortunately, we’re not starting from scratch. There is plenty of good practice in the development world on addressing barriers to accessing health services, and both health and CVA practitioners are learning from this.
What health-related outcomes are we trying to achieve through CVA?
Firstly, let’s be clear: in all contexts, the primary aim of health financing is to provide a social safety net to ensure access to an essential package of quality health services for individuals and households when they need healthcare, without having to suffer financial hardship. This goal is the bedrock of Universal Health Coverage enshrined in Sustainable Development Goal 3 and is even more critical in humanitarian contexts, and at the onset of an emergency.
What this means in humanitarian contexts, is that, at all times, the goal of the health response is to ensure health services are available, accessible and acceptable for the population of concern. Consequently, health financing should focus on restoring and strengthening already existing health systems and health services, in an effort to meet needs by improving the safety and quality of services and to deal with the fact that health workers and/or medicines are likely to be in short supply. Since there are many ways in which health systems may be affected by a humanitarian crisis, there are just as many ways in which health actors respond to these challenges. Given this focus on building or strengthening systems, how can CVA, which is focused on individual households, be useful?
What are the barriers to achieving universal health coverage?
Barriers can be grouped into three categories linked to availability, accessibility (which includes financial accessibility), and acceptability.
Availability of health services is just that. It’s asking whether essential health services of good enough quality are available. This is the first question health actors ask when assessing a situation, particularly in an emergency, where health facilities may be damaged or destroyed. The next question is whether there are enough health workers available, and do they have the training, skills and experience they need?
Accessibility is different from access – accessibility covers not only whether the services are geographically accessible, but also concerns issues such as transport links and opening hours. Health services may be available in principle but not truly accessible to a portion of the population.
Accessibility also relates to the financial barriers to accessing services, which are likely to be among the most important barriers for populations in humanitarian settings. Much as in more stable development contexts, financial barriers in humanitarian settings include the costs that people incur using health services. These costs include indirect costs, such as transportation charges as well as direct costs, such as having to pay for consultations and medicines (out-of-pocket fees) or buying critical preventive commodities such as bed nets. Accessibility also encompasses whether there is a financing structure already in place such as national health insurance coverage or a social protection programme that aims to improve access to healthcare.
Acceptability refers to cultural preference and health literacy, including language barriers, particularly for refugees and IDP’s. This also includes discrimination against various population groups which will make the service unacceptable to those who feel unwelcome or stigmatized against.
Cash and voucher assistance is most useful in improving access when the barrier is a direct or indirect financial cost. But, CVA practitioners are already familiar with the inclusion of a basic level of provision for health costs being included in Minimum Expenditure Calculations. Why is this not enough?
Using CVA to overcome direct or indirect financial barriers. Why is this not straightforward?
Why is including some level of health costs in the MEB not sufficient? There are four main reasons:
1. Full health needs and costs cannot be averaged across households
While every sector is different, quantifying, averaging and costing health needs presents particular challenges. Unlike kilocalories, used by the food security cluster to quantify food needs at household level, health needs are difficult to quantify and predict among household members. One member could have a chronic illness, another could be pregnant and yet another be currently in good health. Such needs are very different and often unpredictable or untimely. In other words, health needs are difficult to standardize.
Nor do the costs of health services lend themselves to averaging due to the wide range in types and costs of health services, including prevention and medication. While the approach of costing needs in other sectors typically involves calculating a minimum expenditure basket, this only works to a limited extent in calculating ‘average costs’ for health services given the wide variation in types of service and in the range of costs from very low to extremely high – from a paracetamol or an MMR jab to chemotherapy or heart surgery. (It is this variation, of course, which is the key rationale for mechanisms such as health insurance that pool individual risk).
2. Information asymmetries between patient and health care provider
Doctors know more than patients. The person (the patient) needing services may not know what their illness is or what treatment they need. This problem is the critical issue of information asymmetries between patients and health care providers and it easily leads to market failure. This asymmetry can lead to a misuse of power (i.e. over-treatment or under-treatment) by medical staff when services are not quality controlled.
3. No set market price for health services
Compounding these challenges, and linked to the point about information asymmetry and to the variation in price for services, there is not necessarily a straightforward market price for health services. Households or individuals may use private healthcare or opt for informal health services to avoid certain costs but may, as a result, end up purchasing medicines and services of poor quality. This can leave the patient sicker and a lot poorer.
4. High costs and low availability of health services in crisis contexts
Finally, in an emergency, health services may not be available or accessible for portions of the population. And, even when services are available and provided at no cost, households consistently report high expenditures related to health which can be up to 60% or more of the financial support they are receiving through multipurpose cash transfers. Why is this? These costs may arise from the cost of access or low availability and include such examples as paying out of pocket for treatment or sourcing medication from a pharmacy because it is out of stock at a ‘free’ public clinic. Patients routinely pay for indirect costs to accessing health services such as transport and accommodation. And when individuals and households have to shoulder the full cost of a health need, they are exposed to financial hardship, which can and does lead to delayed treatment (with all the problems this can bring) and/or negative coping mechanisms, as well as a much higher risk of longer-term impoverishment or ill health.
Cash to improve health outcomes – what to bear in mind.
What steps should practitioners follow to use CVA to support health objectives? While the optimal response option for reducing direct health costs is first to explore provider payment mechanisms that will reduce the application of user fees, CVA has the potential to add value to existing humanitarian health efforts in order to improve access to, and utilization of health services and to achieve better health outcomes.
Firstly, Both CVA and health actors, coordinating where possible, need a proper response analysis from which to develop a response option. This will firstly evaluate, and then address problems related to the supply of healthcare (i.e. restoring health services); and, secondly, identify the existing and potential barriers to access for people of concern. A response analysis should include a review of provider payment mechanisms in place, and response options must address the need to reduce user fees (e.g. enrolment in an existing social health insurance, or humanitarian donor and partner funding to facilitate access to NGO health services, or mobile clinics to provide free services directly to the beneficiaries, etc.). But CVA can address both the direct and indirect costs of health care e.g. via vouchers for the provision of health goods and services and conditional and unconditional cash for transportation and other services. However, it is important to make sure that CVA for health does not encourage a fee-charging culture for health services as this will undermine the goal to achieving universal health coverage.
Where can you learn more?
There is, of course, a lot more that can be said about how cash and voucher assistance can complement access to health services in humanitarian contexts. Well-planned voucher programming, for example, may also be used to improve availability (see the CALP Network/WHO Case Study on Bangladesh). The Global Health Cluster (GHC) and its Cash-Based Intervention Task Team have also developed several guidance resources on the use of CVA for health outcomes.
The CALP Network, with support from GFFO, and in collaboration with key regional and global stakeholders including WHO, is publishing a Health Synthesis paper which reviews examples of current and forthcoming approaches to using cash for health outcomes in the MENA region but also draws on practice more globally. The synthesis also includes a further iteration of a conceptual framework for classifying CVA for health modalities.
To finish on a positive note, the evidence suggests that the use of CVA to promote health outcomes is growing and improving, particularly in reducing financial barriers. The CALP Network’s Health Synthesis Paper found that CVA for health nearly always complements supply-side interventions. This fits with other evidence demonstrating that CVA is often highly effective when coupled with other interventions such as protection or education. The CALP Network review also includes a new conceptual framework for classifying CVA for health modalities.
In the image: Patient involved in IFRC’s Covid response in Lebanon. Credit: IFRC. 12 February 2021.
About the author:
Yassmin Moor is a Cashcap Advisor seconded to the WHO to support the Global Health Cluster Cash Task Team. She has been in the humanitarian sector for the past 15 years, of which the last 7 years focused on cash and voucher assistance. She is based in Jordan.