A presentation from the 2014 Annual Results and Impact Evaluation Workshop for RBF, held in Buenos Aires, Argentina.

1. HEALTH
VOUCHER
PROGRAMS
Ben Bellows
Annual Results and Impact Evaluation
Workshop 2014
Buenos Aires

2. 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.

3. Equality of inputs vs outputs

4. 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.

5. 40 reproductive health voucher programs
0
5
10
15
20
25
30
1964 1985 19951996199719981999200020012002200320042005200620072008200920102011
Active voucher programs each year
Small programs (<$250k)
Medium programs ($250k-$1m)
Large programs (>$1m)

6. 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

7. 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

8. 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.

9. 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

10. 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.

11. 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.

12. 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

13. Thank you