BackgroundDeveloping 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.MethodologyThe 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.ResultsAll 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.ConclusionsWhile 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.

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States of fragility and insecurity often give rise to urgent health needs that need to be met quickly and effectively, particularly for women and adolescents. Vouchers are a demand-side financing mechanism which can be used to address some of the health challenges faced by women under these circumstances. A number of organisations have begun to use vouchers to enable access to reproductive, maternal and newborn care services in conflict-affected countries such as Yemen, Syria and Central African Republic. Vouchers allow health programme implementers to use targeted subsidies to reduce financial and other barriers to accessing care, increasing and catalysing the uptake of specific health services among vulnerable and underserved populations. These subsidies are passed onto public and private providers in the form of service reimbursements and are often used to enhance capacity to meet increased demand for services, as well as to invest in quality improvements. Yemen is one of the poorest countries in the Middle East and North Africa region, and since 2010 has consistently appeared on the lists of fragile states. We present data from the Reproductive Health Voucher Programme in Yemen to show that during 2014, when the conflict was worsening and public facilities faced significant challenges to keep functioning, the vouchers enabled women to continue accessing quality maternal newborn health services. By contracting a range of public and private providers, from referral hospitals to community midwives, the number of services utilised in one governorate in Yemen was consistently higher (17% or more) than the predicted number for all services utilised that make up the safe motherhood voucher package. The programme was able to channel funds to facilities at a time when funds flowing to the governorates were highly erratic, enabling them to address stock-outs of drugs and supplies at the local level and to maximise the supply of critical maternal newborn health services for poor women and their families.

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ObjectiveTo estimate the economic cost associated with implementing the Results Based Financing for Maternal and Newborn Health (RBF4MNH) Initiative in Malawi. No specific hypotheses were formulated ex-ante.SettingPrimary and secondary delivery facilities in rural Malawi.ParticipantsNot applicable. The study relied almost exclusively on secondary financial data.InterventionThe RBF4MNH Initiative was a results-based financing (RBF) intervention including both a demand and a supply-side component.Primary and secondary outcome measuresCost per potential and for actual beneficiaries.ResultsThe overall economic cost of the Initiative during 2011–2016 amounted to €12 786 924, equivalent to €24.17 per pregnant woman residing in the intervention districts. The supply side activity cluster absorbed over 40% of all resources, half of which were spent on infrastructure upgrading and equipment supply, and 10% on incentives. Costs for the demand side activity cluster and for verification were equivalent to 14% and 6%, respectively of the Initiative overall cost.ConclusionCarefully tracing resource consumption across all activities, our study suggests that the full economic cost of implementing RBF interventions may be higher than what was previously reported in published cost-effectiveness studies. More research is urgently needed to carefully trace the costs of implementing RBF and similar health financing innovations, in order to inform decision-making in low-income and middle-income countries around scaling up RBF approaches.