IHP 670 Module Six Program Critique Guidelines and Rubric

IHP 670 Module Six Program Critique Guidelines and Rubric

Overview

You will complete five program cri�que assignments in the course to support your work as you prepare for your final project. These assignments ask that you cri�que a program described

within an iden�fied ar�cle located in the module’s resources. These ar�cles were chosen because they relate to the module’s topics and demonstrate some common problems that programs

encounter. In each assignment, you will have the opportunity to cri�que certain program components, such as resources, ac�vi�es, outcome measures, use of feedback loops, assump�ons,

and external barriers. Once planners have iden�fied the details for each of the program components, they must step back and assess how those components can best operate within the

program’s environment. That involves considering concepts such as cultural competency, systems thinking, ethical prac�ce, and others. You will focus on these different concepts, in turn,

through the program cri�ques. As you develop your program cri�que skills, you will be asked to iden�fy areas that could be or need to be improved and offer recommenda�ons.

In this assignment, you will cri�que a health or healthcare program selected for you. It is the program cri�que reading in the Resources sec�on of the module. This is the only reading that can

be used for this assignment.

This assignment will help you examine ac�vi�es used to improve par�cipa�on in a sexual and reproduc�ve health program. Pay par�cular a�en�on to the ac�vity that was designed to

remove an external barrier to care. Focus your cri�que on elements such as the risks involved, the benefits or desired results, and the intended results achieved to evaluate the program’s

ability to adjust.

This program cri�que will help you plan for the risks and external barriers to your program and improve the program’s ability to adjust and adapt over �me.

Prompt

Write a program cri�que that examines a health or healthcare program intended to meet a specific health need.

Specifically, you must address the following rubric criteria:

1. External Barriers to Care: Describe why it is important to iden�fy barriers that impede an individual’s or a group’s access to care. Consider the following ques�on to guide your

response:

Why do you think the use of vouchers was effec�ve or ineffec�ve in achieving desired results?

2. Program Risks: Describe why iden�fying poten�al risks is important in program planning. Consider the following ques�ons to guide your response:

What two risks did the program create?

What ac�ons would you take to minimize these risks?

3. Program Benefits: Describe what secondary benefits are achieved in addi�on to the desired results and their importance to stakeholders and the overall program. Consider the

following ques�ons to guide your response:

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Why is it important to appreciate these secondary benefits?

How would you let other program planners know about these secondary benefits?

4. Impact on Desired Results: Determine whether the planned ac�vi�es achieved the desired results for the program and why you feel they did or did not achieve these results. Consider

the following ques�on to guide your response:

How might the ac�vi�es be adjusted for improving the program’s desired results if the program were to run again in the future?

Note that all the claims in your deliverable should be evidence based. Your cita�ons should be from your independent search for evidence (not from the scenario, textbook, or module

resources) of credible sources and be current within the last five years. You are required to cite a minimum of one source overall. Refer to the Shapiro Library Guide: Nursing—Graduate

located in the Start Here sec�on of the course for addi�onal support. If you need wri�ng support, access the Online Wri�ng Center through the Academic Support module of your course.

What to Submit

Your submission should be a 2- to 3-page Word document. Also include a �tle page. Use 12-point Times New Roman font, double spacing, and one-inch margins. You should include a

minimum of two sources. Sources should be cited according to APA style.

Module Six Program Critique Rubric

Criteria Exemplary (100%) Proficient (90%) Needs Improvement (70%) Not Evident (0%) Value

External Barriers to Care Exceeds proficiency in an

excep�onally clear and

insigh�ul manner, using

industry-specific language

Describes why it is important

to iden�fy barriers that impede

an individual’s or a group’s

access to care

Shows progress toward

proficiency, but with errors or

omissions

Does not a�empt criterion 20

Program Risks Exceeds proficiency in an

excep�onally clear and

insigh�ul manner, using

industry-specific language

Describes why iden�fying

poten�al risks is important in

program planning

Shows progress toward

proficiency, but with errors or

omissions

Does not a�empt criterion 20

Program Benefits Exceeds proficiency in an

excep�onally clear and

insigh�ul manner, using

industry-specific language

Describes what secondary

benefits are achieved in

addi�on to the desired results

and their importance to

stakeholders and the overall

program

Shows progress toward

proficiency, but with errors or

omissions

Does not a�empt criterion 20

2/11/25, 9:55 AM Assignment Information

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Criteria Exemplary (100%) Proficient (90%) Needs Improvement (70%) Not Evident (0%) Value

Impact on Desired Results Exceeds proficiency in an

excep�onally clear and

insigh�ul manner, using

industry-specific language

Determines whether planned

ac�vi�es achieved the desired

results for the program and

why they did or did not achieve

these results

Shows progress toward

proficiency, but with errors or

omissions

Does not a�empt criterion 15

Ar�cula�on of Response Exceeds proficiency in an

excep�onally clear and

insigh�ul manner

Clearly conveys meaning with

correct grammar, sentence

structure, and spelling,

demonstra�ng an

understanding of audience and

purpose

Shows progress toward

proficiency, but with errors in

grammar, sentence structure,

and spelling, nega�vely

impac�ng readability

Submission has cri�cal errors in

grammar, sentence structure,

and spelling, preven�ng

understanding of ideas

10

Professional Sources Incorporates more than two

professional, current (within

the last five years) sources, or

use of sources is excep�onally

insigh�ul

Incorporates two professional,

current (within the last five

years) sources that support

claims

Incorporates fewer than two

professional, current (within

the last five years) sources, or

not all sources support claims

Does not incorporate sources 10

APA Style Formats in-text cita�ons and

reference list according to APA

style with no errors

Formats in-text cita�ons and

reference list according to APA

style with fewer than five

errors

Formats in-text cita�ons and

reference list according to APA

style with five or more errors

Does not format in-text

cita�ons and reference list

according to APA style

5

Total: 100%

2/11/25, 9:55 AM Assignment Information

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Grainger et al. International Journal for Equity in Health 2014, 13:33 http://www.equityhealthj.com/content/13/1/33

RESEARCH Open Access

Lessons from sexual and reproductive health voucher program design and function: a comprehensive review Corinne Grainger1, Anna Gorter2, Jerry Okal3* and Ben Bellows3

Abstract

Background: Developing countries face challenges in financing healthcare; often the poor do not receive the most basic services. The past decade has seen a sharp increase in the number of voucher programs, which target output-based subsidies for specific services to poor and underserved groups. The dearth of literature that examines lessons learned risks the wheel being endlessly reinvented. This paper examines commonalities and differences in voucher design and implementation, highlighting lessons learned for the design of new voucher programmes.

Methodology: The methodology comprised: discussion among key experts to develop inclusion/exclusion criteria; up-dating the literature database used by the DFID systematic review of voucher programs; and networking with key contacts to identify new programs and obtain additional program documents. We identified 40 programs for review and extracted a dataset of more than 120 program characteristics for detailed analysis.

Results: All programs aimed to increase utilisation of healthcare, particularly maternal health services, overwhelmingly among low-income populations. The majority contract(ed) private providers, or public and private providers, and all facilitate(d) access to services that are well defined, time-limited and reflect the country’s stated health priorities. All voucher programs incorporate a governing body, management agency, contracted providers and target population, and all share the same incentive structure: the transfer of subsidies from consumers to service providers, resulting in a strong effect on both consumer and provider behaviour. Vouchers deliver subsidies to individuals, who in the absence of the subsidy would likely not have sought care, and in all programs a positive behavioural response is observed, with providers investing voucher revenue to attract more clients. A large majority of programs studied used targeting mechanisms.

Conclusions: While many programs remain too small to address national-level need among the poor, large programs are being developed at a rate of one every two years, with further programs in the pipeline. The importance of addressing inequalities in access to basic services is recognized as an important component in the drive to achieve universal health coverage; vouchers are increasingly acknowledged as a promising targeting mechanism in this context, particularly where social health insurance is not yet feasible.

Keywords: Results-based financing, Demand-side financing, Sexual and reproductive health, Maternal health, Voucher program, Social franchising, Poverty targeting, Social health insurance, Incentives, Subsidies

* Correspondence: [email protected] 3Population Council, Ralph Bunche Rd., PO Box 17643-00500, Nairobi, Kenya Full list of author information is available at the end of the article

© 2014 Grainger et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.

Grainger et al. International Journal for Equity in Health 2014, 13:33 Page 2 of 25 http://www.equityhealthj.com/content/13/1/33

Introduction Dramatic gaps in health Globalization is a shorthand term for dramatic economic expansion and growing international interdependence among high-income countries and a large set of post- colonial, low-income countries since the 1980s. That con- vergence also changes the concept of “developing country” as low-income countries cross into the low-middle in- come bracket. Yet as globalization has pulled millions from poverty, it has also opened a widening equity gap within countries in terms of income and health status. There are particularly large gaps in healthcare access, and often the poor and vulnerable do not receive the most basic of reproductive health services [1]. Current health service provision in many low-income

countries does not meet public needs and among the community of aid actors there is frustration with the lack of results achieved by more traditional input-based approaches, such as support for training, infrastructure, drugs and supplies, and behaviour change communica- tion. Many governments are aware of the low perform- ance of their health systems and are ready to test new approaches, particularly those which can target under- served groups with priority health services, such as vou- cher schemes. The proliferation in the number of voucher schemes since 2005, and the dearth of literature which ex- amines lessons learned from program design and imple- mentation, risks the wheel being endlessly reinvented. This paper examines commonalities and differences in voucher design and implementation, and highlights les- sons learned for the design of new voucher programmes, based on a review of 40 programs.

Result-based financing During the last two decades, donors and governments have invested in alternative financing models where finan- cial payments and other incentives are linked to outputs. The umbrella term for these approaches is results-based financing (RBF) [2], defined as "a cash payment or non- monetary transfer made to a national or sub-national gov- ernment, manager, provider, payer or consumer of health services after predefined results have been attained and verified. Payment is conditional on measurable actions be- ing undertaken”. RBF includes a wide range of approaches which vary according to, among other things, the objec- tives, the remunerated behaviours (or indicators), the en- tity receiving the reward and the type and magnitude of the financial reward. The common denominator in all these strategies is payment, in some form, for results as opposed to exclusively financing inputs. A standard categorization is to distinguish RBF schemes

that offer incentives on the supply side (supply-side RBF) from those with an incentive structure primarily on the consumer side (demand-side RBF), although in practice

the boundary between these categories is not clear cut. This is illustrated in Figure 1 below. In a supply-side RBF approach, incentives are paid to the provider based on results reported on a (set of) performance target(s) or in- dicator(s). Where incentives are linked to, say, increased utilisation of services by a specific target group, this will have an indirect impact on the demand-side as health pro- viders put in place more or less successful measures to reach their targets and earn incentives. In demand-side RBF there is a more direct link between the payment of incentives, the actions of the intended beneficiary and the desired result. Vouchers are a demand-side RBF ap- proach with a strong supply-side effect; the behaviour of both provider and consumer is directly influenced by the incentive.

Voucher schemes Vouchers are commonly used to channel subsidies (from governments and/or donors) to stimulate demand for pri- ority health services among specific underserved groups. Figure 2 illustrates the basic structure of a voucher programme. Subsidies go directly to the consumer in the form of a voucher – a certificate, coupon or other token – which the consumer exchanges for the specified goods or services from an accredited or approved health facility (public or private). The provider then claims payment for services provided. Vouchers are usually competitive with multiple providers; however, they can also be non- competitive, i.e. working with fewer providers of a single type [3]. Most healthcare voucher programs have been designed to increase access to one or more sexual and reproductive health (SRH) services. Although there are many variations in the design and

implementation arrangements of voucher programs, they share a number of important characteristics: a funding body (government and/or donors), a governance structure that oversees the program, and an implementing body (e.g. voucher management agency) that distributes vouchers to target populations, approves and contracts facilities to pro- vide services to voucher clients, and reimburses the facil- ities for services provided. Vouchers are proving to be an interesting approach to

overcoming barriers related to accessing SRH care for the poor and other vulnerable groups. There is growing evidence that vouchers promote equity in access to spe- cific health services, can offer financial protection and lead to improved quality of care; cornerstones of the move towards universal health coverage. Two recent sys- tematic reviews of the evidence of the impact of voucher programs on a range of variables found robust evidence that vouchers can increase utilization of health services, and modest evidence that voucher programs both im- prove the quality of service provision and effectively target resources to specific populations [4,5]. Although

Demand side RBF

Health facilities

Supply side RBF

Govt/ donor funding

Management Agency

(Govt/Non- Govt)

Clients

HEF cards/ Insurance

cards/ Vouchers

Claims (vouchers)

Contract $

Services

Entitlement (cards/

vouchers)

Govt/ donor funding

Contracting Agency

(Govt/Non- Govt)

Health facilities/ health

managers

Results data

$

Performance-based financing

and contracting

Figure 1 Supply-side and demand-side results-based financing approaches.

Grainger et al. International Journal for Equity in Health 2014, 13:33 Page 3 of 25 http://www.equityhealthj.com/content/13/1/33

these results were based on the review of relatively few underlying voucher programmes, newly published and newly discovered studies support these findings, and provide new evidence that vouchers are effective at targeting and enhancing equity [6-11]. There are very few studies of the impact of vouchers on health status or efficiency. While recent documentation has focused on analysing

the potential impact of voucher programs, none of the

Figure 2 Key characteristics of voucher programs.

literature has attempted to draw out lessons learned for the design of new programs. The review by Meyers et al., [5] highlighted the fact that program managers of current and future voucher programs would benefit from a review of lessons learned when implementing voucher programs. This paper presents a timely and comprehen- sive review of voucher program design and implementa- tion arrangements based on an analysis of documentation on 40 different voucher schemes.

Grainger et al. International Journal for Equity in Health 2014, 13:33 Page 4 of 25 http://www.equityhealthj.com/content/13/1/33

Methods The objective of the review was to analyse the design and different implementation arrangements for voucher pro- grams for SRH services. Through extensive discussion among the group of au-

thors, all of whom are experts on voucher program design and evaluation, we developed the following inclusion and exclusion criteria for the review:

� The inclusion of all voucher programs for health services which started distribution of vouchers before 28 February 2011. The cut-off date for the review was June 2011 and a period of at least three months of operation was considered necessary in order to look at the functioning of a particular program;

� The inclusion of voucher programs which do not use a physical voucher, but which function in all other respects as a voucher program (e.g. targeting the poor through the use of Below Poverty Line cards in India);

� The exclusion of programs that use vouchers for goods (condoms, pills, insecticide treated bed nets to prevent malaria) as opposed to services. Design and implementation arrangements differ considerably between voucher programs for goods and voucher programs for services. Voucher programs for goods function more like social marketing programs;

� The exclusion of those voucher programs that are operating in high income countriesa;

� The exclusion of programs where there is no reimbursement to the facility or provider. These include programs where a voucher is only used as a marketing tool to attract clients to a facility, where vouchers are used for referral services between health facilities only, or where vouchers are used for research (tracking of clients, data collection, etc.). It also excludes conditional cash transfer programs where there is no provider reimbursement payment since these are pure demand-side programs which do not provide incentives (and therefore do not channel funding) to health service providers as in voucher schemes.

Using the above inclusion and exclusion criteria, we conducted a comprehensive review and compiled a list of all voucher programs. The literature database devel- oped through the DFID systematic review and which in- cluded data up to October 2010 was used as the basis [5]. We then used the same methodology to update this database from April to December 2011 with: (i) searches of bibliographic databases using specified key words (i.e. voucher, coupon, certificate); (ii) a review by hand of the grey literature; (iii) back checking of references for all

selected articles and documents: (iv) checking of organ- isational networks and websites, as well as (v) extensive networking and sourced information from key contacts. The aforementioned review by Bellows et al. (2011)

identified 13 voucher programs, all providing SRH ser- vices in developing countries. The review by Meyer et al. (2011) identified 43 voucher programs, including the 13 programs of Bellows et al. and also including voucher pro- grams for goods (e.g. insecticide treated bed nets) [4,5]. Of the 43, a total of 21 programs fit the criteria for our com- prehensive review, which also identified 19 additional pro- grams giving a total of 40 programs. The database on these 40 identified voucher programmes

was then enhanced through additional searches in order to obtain more detailed information related to context, design and implementation arrangements. Networking and cor- respondence with key contacts was particularly useful in identifying new programs and in providing program de- scriptions (e.g. reports), tools (e.g. contracts, operational manuals, vouchers), and other relevant material. A list of published documents consulted, organised by country, is included as Appendix. We developed a list of 120 program characteristics,

which were thought to be relevant for the design and im- plementation of voucher programs through extensive dis- cussions with voucher experts. The characteristics were extracted from the literature, collected and input into an excel database to facilitate analysis, for example summing (e.g. type of voucher service, type of health service pro- vider), defining averages (e.g. available budget), cross analysis (e.g. type of management agency against type of service providers contracted) and so on. These character- istics were then grouped into five major categories related to design and implementation of the voucher programs:

1. General aspects: size and geographical coverage, statement of objectives, timeframe and financing;

2. Management and governance: structural aspects of voucher programs such as governance, implementing and/or managing entity and its relation to contracted providers; role and participation of government;

3. Benefits and targeting: benefit and client policies such as services covered, distribution strategies (i.e. sold or freely distributed), and targeting approaches;

4. Providers: types of provider; competition; selection and contracting; price of services and reimbursement to providers;

5. Implementation arrangements: marketing, training, voucher distribution, claims processing, monitoring and evaluation, and fraud control.

In this paper, we describe the results of the analysis of these five categories, looking at commonalities and differ- ences and identifying the lessons learned for programmers.

Grainger et al. International Journal for Equity in Health 2014, 13:33 Page 5 of 25 http://www.equityhealthj.com/content/13/1/33

This systematic review of the literature relies on second- ary published and unpublished literature. Ethics review was therefore not necessary.

Results General program characteristics: objectives, financing, size and coverage Forty voucher programs were identified in this compre- hensive review (see Table 1); 22 are still active and 18 ceased to exist. Of the 18 programs that have ended, five programs met their original objectives; five were studies or pilots either taken over by or informing new pro- grams; one program was incorporated into a Health Equity Fund; and seven programs were unable to find new funding, most of them belonging to the older pro- grams developed during the 1990s. A review of voucher program objectives generated a list

of reasons for choosing vouchers over an alternative ap- proach. Nearly all programs address a combination of ob- jectives with the most common being: increasing access to priority services among underserved and vulnerable popu- lations; accelerating the use of underutilized services; and expanding provision of priority services through contract- ing of private sector facilities (e.g. in countries where most providers are private or where there are large gaps in pub- lic service provision). Introducing choice for clients and competition between service providers to drive quality im- provements; and increasing transparency and verification of service delivery are other secondary objectives men- tioned in the literature. An overriding and implicit goal of many voucher programs is that of preventing catastrophic out-of-pocket payments for healthcare among the poor. This is particularly relevant for maternal and newborn health care where the potential treatment costs are un- known when a woman arrives to deliver, and can be very high for complicated cases. The review also shows that vouchers can be used to

curb informal payments (e.g. Armenia) or to introduce social health insurance capacity into the health sector (e.g. voucher programs financed by the German Devel- opment Bank, KfW, in Cambodia, Kenya, Tanzania and Uganda

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