External evaluation of the health ticket - The Voucher approach implemented by FAIRMED, Lobaye Primary Health Project (PSPL)

The FAIRMED Foundation has been present in Africa as an NGO since 1959 (Cameroon). FAIRMED has significant experience in CAR, based on its reputation on Neglected Tropical Diseases, particularly through the technical and financial support to the national programme that it has been supporting since its creation without interruption.
The Lobaye Primary Health Project (PSPL) which began in 2010 in the Mbaïki Health District (HD). The PSPL carries out health system strengthening activities targeting the Aka and more vulnerable populations with a focus on neglected tropical diseases and maternal health.
Conceived as a complementary mechanism to results-based financing, the health ticket (TS), a component of the PSPL, had set itself the objective of increasing the demand for care from marginalised populations, in this case the Aka pygmies living in the Mbaïki district and more precisely in the 14 health areas accredited by FAIRMED for TS, with a view to contributing to the reduction of maternal and infant mortality.
The Aka population in this area is estimated to be around 15,000 people, or 12% of the population.

The evaluation of the Health Ticket (TS) component of the LSPP had the following six objectives:
1.    Evaluate the methodology (modality of intervention) proposed at the beginning of the project (health ticket) ;
2.    Evaluate the quality of the implementation of this methodology;
3.    Assess the impact of the TS approach on the beneficiaries;
4.    Formulate lessons learned for the community, for FAIRMED and for the health system;
5.    Formulate recommendations for the sustainability of the TS approach in the intervention areas and on the beneficiaries;
6.    Position the TS approach in current and future health financing policy in CAR.

The TS was evaluated through a desk study and a field mission that took place in December 2018 with the following 4 methodological steps:
(i) Documentary study accompanied by briefings with the programme managers and instigators of the Voucher approach.
(ii) Methodological validation: the methodology, including the tools to be used during the evaluation, was described in a specific document finalised with the PSPL team on site in Bangui and validated remotely with the FAIRMED team before the field visit.
(iii) Data collection in the field.
(iv) Reporting (interim and final report after stakeholders' return).

The TS was initiated as a pilot project in 2012 and 2013 before being integrated into the FAIRMED Lobaye Health Project (PSPL) in its phase 2 which will run until 2020. It guarantees Aka women who benefit from it free access to prenatal consultations and deliveries, with FAIRMED reimbursing medical expenses to accredited health facilities and paying an allowance to pregnant women for transport during prenatal care and for food during delivery.

This system has proven effective in bringing the Aka, who mostly live in the forest, to the health centre. Through a targeted approach to this vulnerable population, the TS enables: the social mobilisation of the Aka, their information on the care offered and the importance of essential health practices, the identification and affiliation of beneficiaries for free care, and the monitoring of the services provided to them while allowing dialogue between communities and health facilities through the project.

The TS is a complementary mechanism to other support for the strengthening of the health system from which it benefits indirectly through the increase in the provision of care. Indeed, FAIRMED's other activities, through the PSPL on the one hand and the Humanitarian Emergency Medical Aid Project (PAHUM) on the other, help to guarantee the availability and quality of care.

However, a number of challenges have been observed with the TS, particularly in relation to debts contracted with health facilities. The most obvious reasons appear to be resolvable, as they lie in the absence of clear and precise procedures, the absence of an information and data analysis system (themselves not always coherent), and the absence of a limit to the amount of care provided. The health facilities, for their part, are in need of support, particularly in terms of equipment. In addition, the problem of the vulnerability of the Aka remains unresolved. They are forced to confront the "modern world", particularly in terms of health, but live without financial or material resources to meet their growing needs. Even more serious are the acts of discrimination, domination and even violence against the Aka.

However, the TS carried by FAIRMED, which enjoys the credibility necessary to promote this approach, is an innovative health financing mechanism in CAR that offers potential as a vehicle for targeted subsidies such as the current one for free mother and child care. In this way, TS complements other mechanisms such as cost recovery or PBF, all of which, when coordinated together, will enable CAR to move towards an effective Universal Health Coverage approach.

The evaluation povides 3 main recommendations:
(i)    Refine the target population for more precise analyses;
(ii)    Enhance the value of TS with operational research and visibility actions.
(iii)    Implement a TS project in its own right and if possible with cross-sectoral dimensions;

The study aims to provide FAIRMED with elements of decision support.

The geographical area of the evaluation is the one where the Voucher approach was carried out, in the Lobaye Province, Mbaïki Health District.
Institutions met: PSPL team, Ministry of Health and Population at central, district and local level (health facilities).
In addition, focus group meetings with the beneficiaries of the TS enabled the evaluation to be carried out in greater depth from a qualitative point of view.

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