Universal health coverage is an aspirational goal "to ensure that all people obtain the health services they need without suffering financial hardship when paying for them." To move toward greater health coverage, low-income countries can foster health systems that increase utilization, improve scope of services, and reduce financial costs to care. Voucher programs operate on both the demand and supply sides to target subsidies to beneficiaries, who in the absence of the subsidy, would likely not afford the healthcare. Governments that create these programs and take them to scale can expect to see greater utilization of priority health services by disadvantaged and can protect low-income populations from catastrophic health expenditure. As national risk pools mature, these voucher programs can become the foundation for larger, more comprehensive health purchasing agencies that cover the whole population with high quality, low cost healthcare.

1. Can vouchers help move
health systems toward
universal health
coverage?
Ben Bellows
GIC Forum on Health and Social Protection
27 August 2013

2. Problem: inequality within country
"Countries across Africa [and Asia] are
becoming richer but whole sections of society
are being left behind.... The current
pattern of trickle-down growth is
leaving too many people in poverty, too
many children hungry and too many young
people without jobs."
- Africa Progress Panel, May 2012

3. • 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.

4. constraints^3 to financing UHC
in a finite universe
• Trade-offs in three dimensions
1. Utilization: expand population covered?
2. Scope: expand health services offered?
3. Financial protection: increase size of
subsidies per service (or improve
regulation of informal charges)?
How universal can vouchers really be?
Despite growing evidence for vouchers’
mpressive impact in terms of equity,
financial protection and quality of care, they
remain for now a specific tool to enable
underserved groups to access priority
services. However the WHO’s ‘cube’ frames
progress towards UHC in terms of the share
of people, services and costs covered, with
a focus on growing these three dimensions
as far as possible
xi
. Given this
understanding of UHC, how important can
vouchers’ contribution to UHC really be?
The first point to remember is that vouchers
do not have to be targeted. For example, all
families were eligible for the wildly successful Pitfall 1: Social Health Insurance can
Figure 1: WHO's Universal Health Coverage 'Cube'

5. Financing trade-offs
• Finance movement toward UHC either
from a greater budget allocation or
greater efficiency
• Interventions that generate greatest
efficiency will likely operate on supply &
demand

6. Voucher functions (management)
• Decide to government-run, contract-out, or franchise
• Conduct provider administrative & clinical training (i.e. CMEs)
• Design & maintain claims processing & fraud control
• Monitor costs, utilization, quality
• Offer credit to facilities
Facility
• Accredited?
• Clinical quality?
• Competition?
• Reimbursement rates?
Client
• Poverty status & need?
• Voucher is free or fee?
• Which services
offered?
Program design & functions
Objective – reach beneficiaries who in the absence
of subsidy would not have sought equivalent care

7. What can vouchers do & where
are the gaps in knowledge?
• Recent review catalogued 40 programs
that used vouchers for reproductive
health services (excluded TB and
coupons for health products)
• Summarized evidence from multiple
studies of 21 voucher programs

8. Number of active reproductive health voucher
programs
0
5
10
15
20
25
30
Small (<$250k /yr)
Medium ($250k-
$1m /yr)
Large (>$1m /yr)

9. Program contracts with public & private
providers
18
6
10
1
5
0
2
4
6
8
10
12
14
16
18
20
private mostly private mixed mostly public public

10. Outcome
type
Number of
studies
Direction of effect & gaps in research
Equity or
targeting
8 studies Positive effects: inequalities were
reduced.
Missing: nationally standard measures.
Costing 4 studies Positive effects: OOP spending reduced.
Missing: cost-effectiveness,
administrative-to-service delivery ratio
Knowledge 5 studies Positive effects: increased knowledge of
important health conditions.
Missing: measures of community norms
and partner knowledge.
Evaluation outcomes (1 of 2)

11. Outcome
type
Number of
studies
Direction of effect & gaps in research
Utilization 17 studies Positive effects: increased use of ANC,
facility deliveries and contraceptives.
Missing: Postnatal care.
Quality 8 studies Positive effects: improved customer care,
infrastructure upgrades.
Missing: clinical care scores.
Health 8 studies Positive effects: decreases in STI
prevalence, fewer stillbirths, fewer
unwanted pregnancies
Missing: maternal mortality, DALYs
averted, CYPs
Evaluation outcomes (2 of 2)

12. Prospective studies 2009-2013
• Quasi-experimental design for voucher
programs about to launch or expand
• Measure change in:
• utilization (new users, aggregate use)
• equity (concentration indices, standard
quintiles)
• quality of care frameworks (Donabedian,
Respectful Care, facility investments)
• out-of-pocket spending on healthcare

13. Data sources:
• 2 rounds of household surveys
• 4 voucher & 3 non-voucher
sites
• 5 km radius from voucher &
comparison facilities
• Births within two years before
survey
• 2010-11: 962 births among
2,933 women 15-49 years
• 2012: 1,494 births among
3,094 women 15-49 years
Study #1, Demand: Study of voucher
utilization in Kenya
Data sources

14. Analysis
• Cross tabulation with Chi-square tests
• births by place of delivery over time
• Multilevel random-intercept logit analysis
𝑙𝑜𝑔𝑖𝑡 (𝜋𝑖𝑗𝑘)= 𝑋𝑖𝑗𝑘β + µ𝑗𝑘
• Three arm design
• 2006 voucher arm: respondents within 5km of
facilities in program since 2006
• 2010-11 voucher arm: respondents within 5km of
facilities added to program in 2010 & 2011
• Comparison arm: respondents within 5 km of non-
voucher facilities
14

15. 2006 voucher
arm
2011 voucher
arm
Comparison arm
Place of
delivery
First
survey
Second
survey
First
survey
Second
survey
First
survey
Second
survey
Home 32% 21% 59% 47% 45% 42%
Health
facility
66% 79% 39% 51% 54% 57%
Public
facility
45% 49% 32% 36% 41% 44%
Private
facility
21% 30% 7% 15% 13% 13%
p-value p<0.01 p<0.01 p=0.59
Change in place of delivery

16. Outcome 2006
voucher arm
2010-11
voucher arm
Comparison
arm
Facility
delivery
2.04**
(1.40-2.98)
1.72**
(1.22-2.43)
1.32
(0.96-1.81)
Home delivery 0.53**
(0.36-0.78)
0.61**
(0.43-0.85)
0.75
(0.54-1.03)
Adjusted odds ratios
• Changes consistent with increased use of
vouchers by respondents
• 2006 voucher arm: 20% -> 43%
• 2010-11 voucher arm: 11% -> 45%
• Comparison arm: 0% in both rounds

17. Limitations of analysis
• Teasing out direct and indirect effects of
the program on facility delivery
• Identification of respondents within
specified distances to facilities could affect
over or under-estimation of impact
• Most covariates for multivariate analysis
pertain to time of interview
• Changes in time dependent co-variates
could affect access to facilities

18. Study
#2,
Supply:
Facility
use
of
reimbursements
• Cross
sectional
data
from
77
accredited
facilities
• Retrospective
measurement
of
how
accredited
facilities
allocated
revenues
across
six
standard
cost
categories
for
phase
1
(2006-­‐2008)
and
phase
2
(2008-­‐2011)
• A
structured
questionnaire
sent
to
accredited
facilities
• 88%
response
rate
achieved
• Responses
analyzed
to
show
percentages
of
revenue
used
in
standard
accounting
categories

19. Use
of
revenue
by
category
in
Phase
2
9%
6%
33%
35%
11%
7%
0%
5%
10%
15%
20%
25%
30%
35%
40%

20. Revenue
source
before
vouchers
program
Prior
to
the
GoK
Voucher
program
81%
of
the
facili7es
reported
that
following
the
launch
of
the
voucher
program,
the
voucher
program
has
been
their
main
revenue.
Revenue
Source
Public
Facilities
Private
Facilities
FBOs
Government
50%
0
0
Self-­‐generated
revenue
31%
57%
53%
Bank
Loans
0
43%
0
Donors
19%
0
37%

21. Facilities
also
reported…
Challenges
in
accessing
and
purchasing
medical
and
non-­‐
medical
supplies.
Voucher
revenue
used
to:
1. Cover
the
financing
shorDall
for
purchases
2. Increase
capacity
and
provide
more
services
3. Improve
service
quality
and
increase
pa7ent
volumes/
bed
capacity
Flexibility
in
using
revenue
may
help
overcome
perennial
problems
of
centrally
managed,
public
sector
supply
and
commodity
constraints
and
private
sector
financing
gaps
to
provide
beMer
healthcare
services.

22. In a scaled vouchers strategy that
moves us toward UHC, which trade-
offs would be less painful than others?
Is this a more efficient option p than
alternatives?How universal can vouchers really be?
Despite growing evidence for vouchers’
mpressive impact in terms of equity,
financial protection and quality of care, they
remain for now a specific tool to enable
underserved groups to access priority
services. However the WHO’s ‘cube’ frames
progress towards UHC in terms of the share
of people, services and costs covered, with
a focus on growing these three dimensions
as far as possible
xi
. Given this
understanding of UHC, how important can
vouchers’ contribution to UHC really be?
The first point to remember is that vouchers
do not have to be targeted. For example, all
families were eligible for the wildly successful Pitfall 1: Social Health Insurance can
Figure 1: WHO's Universal Health Coverage 'Cube'

23. US$
millions
70%
coverage
of
2
lowest
quintiles
2013
2014
2015
Service
delivery
cost
23
29
32
Management
cost
(15-­‐20%)
3
6
6
Total
cost:
Maternal
voucher
27
35
38
%
MOH
2011-­‐12
budget
$813m
3.3%
4.3%
4.7%
Family
planning
service
cost
16
17
20
Management
cost
(15-­‐20%)
3
3
3
Total
cost:
FP
voucher
19
20
22
%
MOH
2011-­‐12
budget
$813m
2.3%
2.5%
2.7%
Think like a demographer. An incremental
allocation could take vouchers to scale

24. UHC & vouchers - Equity
• Voucher clients are often identified as poor,
with a low likelihood of using care
• Vouchers educate households to use service,
even when the service is free (“patient’s
charter”)
• Vouchers can control informal payments
• Vouchers provide managers with data on
eligible households, utilization, and feedback
on populations that need extra mobilization
• Vouchers can be targeted to the poor to pay
their insurance premiums

25. UHC & vouchers- Financial
protection
• Voucher clients receive a subsidy and
avoid paying out-of-pocket at point-of-
care
• Voucher programs often contract
private facilities, which expand access
and improve the likelihood that
households will avoid OOP

26. UHC & vouchers- Quality of care
• Accreditation standards screen out
underperforming facilities
• Reimbursements paid conditional on
meeting minimum service delivery
requirements
• Quality-adjusted reimbursements are
possible
26

27. Thank you
RHVouchers.org
@benbellows
bbellows@popcouncil.org