Lessons from sexual and reproductive health voucher program design and function: a comprehensive review

Abstract

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.

Providing safe motherhood services to underserved and neglected populations in Yemen: the case for vouchers

“…However, based on our long experience of supporting and researching voucher programmes for reproductive health (Gorter et al 2012;Grainger et al 2014;Gorter et al 2013), and in particular our engagement with the delivery of the voucher programme in Yemen, we have observed that vouchers can and do facilitate access to specific services when traditional supply-side approaches are unable to do so.…”

“…Vouchers can be used for a range of services and have most commonly been used to improve access to reproductive health services such as family planning and safe motherhood services (Gorter et al 2012;Grainger et al 2014).…”

“…Vouchers have a long history of use for increasing access to specific, underutilised health services among underserved or neglected populations (Gorter et al 2012;Grainger et al 2014). Although vouchers have been widely used to enable access to food, clothing and other shelter in conflict and humanitarian settings, the approach has not traditionally been employed to enable access to health services in these contexts (Levine and Bailey 2015).…”

“…Experience from a number of reproductive health voucher programmes shows that over time, providers tailor their services and become more responsive to the needs of the target group, with the aim of attracting more women (Gorter et al 2013;Gorter and Bayou 2011). Reviews of voucher programmes show that the reimbursement funds are used for a range of purposes by participating facilities, including additional training for staff, purchase of critical supplies such as for infection prevention, and to make facilities more welcoming (increased privacy, improved hygiene and so on) (Gorter et al 2012;Grainger et al 2014;Kanya 2013).…”

Cervical cancer screening: barriers to access and potential solutions for Nigeria

“…These have been used in Uganda, Pakistan, and India 47 . The majority of these schemes used targeted mechanisms to deliver subsidies to individuals, who in the absence of the subsidy would likely not have sought care.…”