HEALTH  VOUCHER  PROGRAMS    

Ben Bellows Annual Results and Impact Evaluation

Workshop 2014 Buenos Aires

Inequitable access to MNCH services*

•  Of 12 MNH interventions in a review of public data across 54 countries, family planning was the third most inequitable

*Barros, A. J. D., Ronsmans, C., et al. (2012). “Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries”. Lancet, 379(9822), 1225-33.

Equality of inputs vs outputs

Counterfactual

•  Vouchers are targeted to poor beneficiaries who, in most cases, would not have used the service if the voucher were not available, thus reducing inequity and helping the health system move toward universal healthcare coverage.

40 reproductive health voucher programs

0

5

10

15

20

25

30

1964 1985 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Active voucher programs each year

Small programs (<$250k)

Medium programs ($250k-$1m)

Large programs (>$1m)

Types of active voucher services in 40 programs

0

5

10

15

20

25

30

SMH services Family Planning RTIs/STIs Child Diseases SRH care for youth

Safe Abortion Cervical Cancer screening

Gender Based Violence

no. VPs

Contracted providers by sector

18  

6  

10  

1  

5  

0  

2  

4  

6  

8  

10  

12  

14  

16  

18  

20  

private   mostly  private   mixed   mostly  public   public  

Evaluation outcomes (1 of 2)

Outcome type Number of studies Direction of effect & gaps in research

Equity or targeting

8 studies Positive effects: inequalities were reduced.

Research gap: nationally standard measures.

Costing 4 studies Positive effects: OOP spending reduced.

Research gap: cost-effectiveness, administrative-to-service delivery ratio

Knowledge 5 studies Positive effects: increased knowledge of important health conditions.

Research gap: measures of community norms and partner knowledge.

Evaluation outcomes (2 of 2)

Outcome type Number of studies

Direction of effect & gaps in research

Utilization 17 studies Positive effects: increased use of ANC, facility deliveries and contraceptives.

Research gap: Postnatal care.

Quality 8 studies Positive effects: improved customer care, infrastructure upgrades.

Research gap: clinical care scores.

Health 8 studies Positive effects: decreases in STI prevalence, fewer stillbirths, fewer unwanted pregnancies

Research gap: sensitivity analysis, DALYs averted

Recommendations: Voucher management

•  Engage a voucher management agency (VMA) as a third party independent from service providers and government.

•  Raise awareness with marketing. •  Be aggressive on fraud control. Routinely

verify voucher distribution, claims management, and clinical care.

Recommendations: Providers and clients

•  Contract providers widely from public, NGO/FBO, & private sectors.

•  Use available data to periodically track competition between providers.

•  Gauge how likely ‘new’ clients are to use the services. Focus on increasing the number of new users.

•  Determine how attractive the reimbursements are and how quickly payment process works for providers.

Conclusions: Challenge is scale

•  Large programs operate at $1m-$2m per year •  Deliver 3-5% of all births in Cambodia, Kenya,

Bangladesh and Uganda –  6-10% of all facility births in Kenya & Uganda –  50% of all Long-Acting and Permanent FP methods in

some counties of Kenya •  Greater efficiency helps programs to scale from 3%

to 30% of general population •  Standard performance metrics to track impact

needed in larger programs

Thank you