Key characteristics of voucher programs. 

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... 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 income 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 communication. Many governments are aware of the low performance of their health systems and are ready to test new approaches, particularly those which can target underserved groups with priority health services, such as voucher schemes. The proliferation in the number of voucher schemes since 2005, and the dearth of literature which examines lessons learned from program design and implementation, risks the wheel being endlessly reinvented. This paper examines commonalities and differences in voucher design and implementation, and highlights lessons learned for the design of new voucher programmes, based on a review of 40 programs. During the last two decades, donors and governments have invested in alternative financing models where financial 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- ing undertaken ” . RBF includes a wide range of approaches which vary according to, among other things, the objectives, the remunerated behaviours (or indicators), the entity 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 providers 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 approach with a strong supply-side effect; the behaviour of both provider and consumer is directly influenced by the incentive. Vouchers are commonly used to channel subsidies (from governments and/or donors) to stimulate demand for priority 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 provide services to voucher clients, and reimburses the facilities 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 specific health services, can offer financial protection and lead to improved quality of care; cornerstones of the move towards universal health coverage. Two recent systematic 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 improve the quality of service provision and effectively target resources to specific populations [4,5]. Although 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 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 comprehensive review of voucher program design and implementation arrangements based on an analysis of documentation on 40 different voucher schemes. The objective of the review was to analyse the design and different implementation arrangements for voucher programs for SRH services. Through extensive discussion among the group of authors, all of whom are experts on voucher program design and evaluation, we developed the following inclusion and exclusion criteria for the review: Using the above inclusion and exclusion criteria, we conducted a comprehensive review and compiled a list of all voucher programs. The literature database developed through the DFID systematic review and which included 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 services 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 programs for goods (e.g. insecticide treated bed nets) [4,5]. Of the 43, a total of 21 programs fit the criteria for our comprehensive review, which also identified 19 additional programs 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 descriptions (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 implementation of voucher programs through extensive ...