March 26, 2014
Many women in developing countries, too poor to pay for the reproductive health services they need, use vouchers to defray the cost of care.
Voucher programs have been developed for family planning, prenatal and postnatal visits, childbirth assistance, and screening for sexually transmitted infections.1 In countries like Kenya, where only 44 percent of women deliver their babies in a health facility, a lack of skilled assistance during childbirth puts both the mother and child at risk.2 Voucher programs target women who otherwise might not seek care, and aim to improve the quality of reproductive health products and services by creating incentives for participating providers to respond to women’s needs.
About 40 voucher programs have been piloted in developing countries. Ben Bellows, an epidemiologist with the Population Council, and who evaluates voucher programs in East Africa and South and Southeast Asia, writes that the health care choices for poor women are complex, “Long queues, stock-outs, absent staff, and other supply-side constraints at public facilities can make that option very unappealing during a health emergency.” Bellows also notes that in private facilities with no subsidy program, poor women can be “priced out of care” or financially devastated by a catastrophic illness.
Vouchers are free or low-cost. Women choose a provider and redeem the voucher for the product or service they need. According to Bellows, the voucher “helps low-income beneficiaries to afford care in private facilities that can be more responsive to patients.” Bellows notes that voucher programs can also be an efficient mechanism for rewarding high-performing public facilities that see women promptly. Providers render the service and seek reimbursement from a voucher management agency that creates and distributes the vouchers to the target population and administers the program.
Participating providers must maintain a minimum level of standards for quality, which can translate into improved staff training, increased efficiency, and competitive control on costs. According to Bellows, “Although the voucher services packages are often narrowly defined, one of the unspoken benefits of a voucher program…is that the government can strengthen its regulatory role through contractual service delivery.” Facilities participate only “if they meet quality standards to join; facilities only continue in the program if they provide services at agreed levels of care,” he explained.
Findings from two systematic reviews demonstrated voucher program benefits—effective targeting of specific populations, increased service use, and improvements in quality.3 The Population Council is currently evaluating reproductive health voucher programs in five countries—Kenya, Tanzania, Uganda, Cambodia, and Bangladesh. Preliminary results from this evaluation are generally consistent with the earlier findings, according to Bellows.
In Kenya, a government voucher program for safe motherhood subsidized up to four prenatal care visits, delivery, postnatal care for six weeks, emergency Caesarean surgery (if necessary), and treatment of maternal and neonatal complications, along with long-term family planning in five areas in Nairobi. Women who participated in the voucher program were significantly more likely to have delivered at a health care facility and to have received skilled delivery care.4 Kenya has included a scale-up of the voucher approach in its Vision 2030 economic development plan.5
In Uganda, one medical center saw a rapid increase in deliveries when it launched its voucher program—from 15 deliveries for the entire year in 2008 to 58 per month between January and July of 2010. Another pilot voucher program in Uganda for screening and treatment of sexually transmitted infections was linked to significant decreases in the prevalence of syphilis and gonorrhea.6
Funders like the German Development Bank and the World Bank recognize that these programs are still new. Challenges include high set-up and administrative costs and the persistent difficulties of reaching the poorest and most remote women.7 The World Bank cites claims management as the most pressing challenge, but preventing fraud also poses problems. In some cases, voucher distributors who were paid per number of vouchers sold were found to be selling vouchers to women who did not qualify.8 Other critics say that vouchers do not expand patient choice in remote areas where there is only one facility.
For Bellows, after five years on the ground working out the logistics and evaluating the outcomes, the next big challenge is sustainability. Many facilities have invested in infrastructure, supplies, and staff in order to participate and be more responsive to patient needs. Some governments are on board, but the majority of financing still comes from bilateral and multilateral donors and foundations, Bellows says. Still, he notes that since 2005 the number of programs has grown, with approximately 30 currently active. And governments in low- and middle-income countries have become more interested.