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Lessons Learned for Voucher Program Design
What this and previous reviews have shown is that voucher schemes are a means to channel scarce financial resources to those groups identified as having priority needs, or to those services identified as having a public health imperative (i.e. STI diagnosis and treatment, FP, institutional deliveries, and...
Context in source publication
Context 1
... voucher programs that are managed by government agencies, there is a wide range of different management structures in place, while the voucher programs managed by non-government agencies (either for-profit or not-for profit) tend to have management structures that are much more similar and aligned with the diagram presented in figure 2 (page 5) in Section 1. ...
Citations
... Vouchers for free mammography can significantly improve compliance rates in rural regions [17]. Some evaluations of voucher programs have reported positive associations with increased utilization [10,18,19]. Widespread acceptance of the governmental tool led the World Bank to issue a guide for vouchers; this guide identified the advantages of vouchers and highlighted the choices and decisions involved in using vouchers [13]. ...
... Utilization statistics for public healthcare services were derived from the Hospital Authority Statistical Reports and Thematic Household Survey Report [3,29,30]. Baseline EHCV statistics were derived from the literature, the interim report of the Department of Health (DH), the published survey from the Hong Kong Medical Association [18][19][20][21][22], and crosssectional studies (unpublished). The cross-sectional studies included a repeated cross-sectional survey of elderly persons aged 70 or above assessing their changes in attitudes toward, and usage of, vouchers among elderly persons in the community. ...
Background
The elderly healthcare voucher (EHCV) scheme is expected to lead to an increase in the number of elderly people selecting private primary healthcare services and reduce reliance on the public sector in Hong Kong. However, studies thus far have reported that this scheme has not received satisfactory responses. In this study, we examined changes in the ratio of visits between public and private doctors in primary care (to measure reliance on the public sector) for different strategic scenarios in the EHCV scheme.
Methods
Based on comments from an expert panel, a system dynamics model was formulated to simulate the impact of various enhanced strategies in the scheme: increasing voucher amounts, lowering the age eligibility, and designating vouchers for chronic conditions follow-up. Data and statistics for the model calibration were collected from various sources.
Results
The simulation results show that the current EHCV scheme is unable to reduce the utilization of public healthcare services, as well as the ratio of visits between public and private primary care among the local aging population. When comparing three different tested scenarios, even if the increase in the annual voucher amount could be maintained at the current pace or the age eligibility can be lowered to include those aged 60 years, the impact on shifts from public-to-private utilization were insignificant. The public-to-private ratio could only be marginally reduced from 0.74 to 0.64 in the first several years. Nevertheless, introducing a chronic disease-oriented voucher could result in a significant drop of 0.50 in the public-to-private ratio during the early implementation phase. However, the effect could not be maintained for an extended period.
Conclusions
Our findings will assist officials in improving the design of the EHCV scheme, within the wider context of promoting primary care among the elderly. We suggest that an additional chronic disease-oriented voucher can serve as an alternative strategy. The scheme must be redesigned to address more specific objectives or provide a separate voucher that promotes under-utilized healthcare services (e.g., preventive care), instead of services designed for unspecified reasons, which may lead to concerns regarding exploitation.
... Second, like many countries in the world which promote their health and social policies to reduce CHE by improving access to health-care services (Gorter et al., 2012;Korenman and Remler, 2013), policy makers in China could consider establishing more clinics and equipping more well-educated physicians in rural areas and low-income urban areas. The more-accessible health-care services, on the one hand, could increase the utilisation of free care and affordable care among lowincome older adults. ...
Older adults have more health-care needs and higher financial burdens but fewer income resources compared to other age groups in China. Meanwhile, substantial inequalities exist between rural and urban older adults in terms of welfare benefits level, access to health care, quality of care and financial resources to pay for health-care services. Using 2011–2013 panel data from the China Health and Retirement Longitudinal Study and a difference-in-differences methodology, this study examined the association between the incidence of catastrophic health expenditure (CHE) and health-related quality of life among older adults in China. To distinguish the dynamic of CHE and generate rigorous estimates, we categorised the older adults into four groups: CHE entry group, non-CHE group, CHE exit group and CHE persistent group. Overall, we found that entry into CHE was associated with poorer physical and mental health for both rural and urban older adults, but this association was more consistent and robust for physical than for mental health. Exiting CHE was found to have a weak and sporadic positive association with physical and mental health across rural and urban areas. The results suggest that financial resources and social services are needed in China to support older adults who experience CHE persistently or periodically to help improve their health outcomes.
... Voucher programs have a long history of increasing access to health services among underserved populations by reducing financial and other barriers to accessing services. 13 They can be used for a range of services but have been most commonly applied to improving access to reproductive health services such as family planning and safe motherhood (the Yemen program covers both). Voucher programs are flexible in their design, effective at leveraging the capacity of both public and private providers of health care, and can be adapted to changing situations and contexts. ...
In conflict-affected states, vouchers have reduced barriers to reproductive health services and have enabled health programs to use targeted subsidies to increase uptake of specific health services. Vouchers can also be used to channel funds to public- and private-service providers and improve service quality. The Yamaan Foundation for Health and Social Development in Yemen and the Marie Stopes Society (MSS) in Pakistan—both working with Options Consultancy Services—have developed voucher programs that subsidize voluntary access to long-acting reversible contraceptives (LARCs) and permanent methods (PMs) of family planning in their respective fragile countries. The programs focus on LARCs and PMs because these methods are particularly difficult for poor women to access due to their cost and to provider biases against offering them. Using estimates of expected voluntary uptake of LARCs and PMs for 2014 based on contraceptive prevalence rates, and comparing these with uptake of LARCs and PMs through the voucher programs, we show the substantial increase in service utilization that vouchers can enable by contributing to an expanded method choice. In the governorate of Lahj, Yemen, vouchers for family planning led to an estimated 38% increase in 2014 over the expected use of LARCs and PMs (720 vs. 521 expected). We applied the same approach in 13 districts of Punjab, Khyber Pakhtunkhwa (KPK), and Sindh provinces in Pakistan. Our calculations suggest that vouchers enabled 10 times more women than expected to choose LARCs and PMs in 2014 in those areas of Pakistan (73,639 vs. 6,455 expected). Voucher programs can promote and maintain access to family planning services where existing health systems are hampered. Vouchers are a flexible financing approach that enable expansion of contraceptive choice and the inclusion of the private sector in service delivery to the poor. They can keep financial resources flowing where the public sector is prevented from offering services, and ensure that alternative sources are available for reproductive health services such as family planning. Programs should consider using vouchers in fragile states to facilitate access to family planning services and support the countries’ health systems.
... To address limitations of current healthcare systems and tackle financial barriers to access, alternative healthcare financing approaches have been developed that link propoor provider payments to outputs. One strategy – referred to as the output-based approach (OBA) – targets priority health services to underserved and/or marginalized populations and reimburses approved health facilities for seeing beneficiaries on a clearly defined service package141516. OBA RH voucher programs have been designed to increase access to sexual and RH services for new users who, in the absence of the voucher , would probably not have sought care [16] . ...
... One strategy – referred to as the output-based approach (OBA) – targets priority health services to underserved and/or marginalized populations and reimburses approved health facilities for seeing beneficiaries on a clearly defined service package141516. OBA RH voucher programs have been designed to increase access to sexual and RH services for new users who, in the absence of the voucher , would probably not have sought care [16] . Available evidence suggests that voucher programs can increase utilization and efficiency of health services and improve quality of services and health status among target population groups161718. ...
... OBA RH voucher programs have been designed to increase access to sexual and RH services for new users who, in the absence of the voucher , would probably not have sought care [16] . Available evidence suggests that voucher programs can increase utilization and efficiency of health services and improve quality of services and health status among target population groups161718. In both Uganda and Nicaragua, voucher programs were associated with decreases in prevalence of selected STIs [19,20]. ...
Continued inequities in coverage, low quality of care, and high out-of-pocket expenses for health services threaten attainment of Millennium Development Goals 4 and 5 in many sub-Saharan African countries. Existing health systems largely rely on input-based supply mechanisms that have a poor track record meeting the reproductive health needs of low-income and underserved segments of national populations. As a result, there is increased interest in and experimentation with results-based mechanisms like supply-side performance incentives to providers and demand-side vouchers that place purchasing power in the hands of low-income consumers to improve uptake of facility services and reduce the burden of out-of-pocket expenditures. This paper describes a reproductive health voucher program that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the program to include public sector facilities.
Data presented here describes the results of interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher program in southwestern Uganda. Interviews were transcribed and organized thematically, barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the program by involving public sector facilities were investigated.
The findings show that access to sexual and reproductive health services in southwestern Uganda is constrained by both facility and individual level factors which can be addressed by inclusion of the public facilities in the program. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher program with other services is likely to address some of the barriers. The public sector facilities were also seen as being well positioned to provide voucher services because of their countrywide reach, enhanced infrastructure, and referral networks. The voucher program also has the potential to address public sector constraints such as understaffing and supply shortages.
Accrediting public facilities has the potential to increase voucher program coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening linkages between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilization of resources to support the sustainability of the programs. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher program.
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.
Background:
Young people often express a preference for seeking family planning information and services from the private sector. However, in many Marie Stopes International (MSI) social franchise networks, the proportion of young clients, and particularly those under 20 years of age, remains low. Marie Stopes Madagascar (MSM) piloted a youth voucher program that joins a supply-side intervention-youth-friendly social franchisee training and quality monitoring-with a corresponding demand-side-component, free vouchers that reduce financial barriers to family planning access for young people.
Methods:
Young people identified by MSM's community health educators (CHEs) received a free voucher redeemable at a BlueStar social franchisee for a package of voluntary family planning and sexually transmitted infection (STI) information and services. BlueStar social franchisees-private providers accredited by MSM-are reimbursed for the cost of providing these services. We reviewed service statistics data from the first 18 months of the youth voucher program, from July 2013 to December 2014, as well as client demographic profile data from July 2015.Findings: Between July 2013 and December 2014, 58,417 vouchers were distributed to young people by CHEs through a range of community mobilization efforts, of which 43,352 (74%) were redeemed for family planning and STI services. Most clients (78.5%) chose a long-acting reversible contraceptive (LARC), and just over half (51%) of young people benefited from STI counseling as part of their voucher service. Most (78%) services were provided in the Analamanga region (the capital and its surroundings), which was expected given the population density in this region and the high concentration of BlueStar franchisees. The client profile data snapshot from July 2015 revealed that 69% of voucher clients had never previously used a contraceptive method, and 96% of clients were aged 20 or younger, suggesting that the voucher program is successfully reaching the intended target group.
Conclusion:
MSM's youth voucher program has revealed a high demand for voluntary family planning services, especially among youth under 20 years old, and MSM has since integrated the youth voucher beyond the initial pilot locations. MSM's experience indicates that youth vouchers are a novel and effective means of increasing young people's access to voluntary family planning services in Madagascar, and this model could potentially be replicated or adapted in other contexts where young people are faced with barriers to accessing quality information and services.
