Evaluating Voucher-and-Accreditation Interventions to Improve Reproductive Health Service Delivery Business Models
The Population Council is studying health voucher programs in East Africa and South Asia and sharing findings with national and global partners.
Lab supervisor Kagumire John and his wife, nurse-midwife Ndahweje Angella, stand outside the clinic they own in Rubindi, Uganda. Angella sees voucher patients for STI complaints and normal maternal deliveries; she refers complicated cases to central hospitals. Photo: Ben Bellows/Population Council
Voucher-and-accreditation (V&A) programs are alternative health service financing models that reduce financial barriers to health care and reduce inequities by making services affordable to the poor and other underserved groups through subsidies. By accrediting several providers to offer particular services at the same price (which is heavily subsidized for the patient), these programs can increase choice for patients and increase efficiency in delivery. The provider is reimbursed at a negotiated rate that reflects the cost of service provision and a reasonable profit. Service providers are reimbursed only after verification of contractually delivered services.
Voucher programs are designed with several objectives in mind: to give patients the economic power to demand high-quality healthcare, to target high-risk or low-income patients for critical services, to augment general population utilization rates, and to contain per-unit costs.
In 2009 the Population Council began a project to document, evaluate, and share findings on voucher programs. The Council aims to generate evidence that can help governments and partners decide whether to scale up these programs, include additional services, or support their transition to a different business model, such as social health insurance.
The evaluations will take place in five countries: Bangladesh, Cambodia, Kenya, Tanzania, and Uganda. All of the voucher programs that the Council is assessing have a primary focus on increasing access to safe motherhood services for pregnancy, attended delivery, and postpartum care to poor women who otherwise would not have access to such services. Each country selected additional services as priority areas.
Offsite link: RH Vouchers blog
In Kenya, about 70,000 people were served between June 2006 and October 2008. Additional clients have been seen in the interim, and now as Phase II begins, it’s expected that an additional 100,000 women will be given antenatal, delivery, and postnatal care services over the next three years.
In Uganda, there were 20,000 patient visits to 15 clinics for STI complaints between June 2006 and May 2008. In February 2009, the voucher program began offering maternal delivery services with plans to pay for 53,000 deliveries over the next three years. The first "voucher baby" was born in early 2009 to Jeninah Komugisha, a 35-year-old mother in Uganda who delivered her baby girl in a private facility. "I feel very grateful to the Healthy Baby [voucher] scheme . . ." she said, ". . . there are many more mothers who ordinarily would find it difficult to access such facilities when delivering simply because they lack the money."
In Bangladesh, the Population Council ran a small pilot and subsidized delivery for 1,600 patients. In a second larger pilot program, the Government of Bangladesh subsidized demand and supply of more than 100,000 deliveries since 2006. Over a nine-month period, the proportion of pregnant women not accessing antenatal care decreased from 21 percent to 11 percent, the proportion of women delivering with a skilled attendant increased from 6 percent to 22 percent, deliveries at health facilities increased from 2 percent to 18 percent, and the proportion of women attending for postnatal care increased from 45 percent to 60 percent. Results illustrate the potential contribution of such programs to reducing maternal mortality, thereby helping countries achieve MDG5.
Read more about voucher programs in these countries at the RH Vouchers blog (offsite link).
Voucher programs will begin later this year in Cambodia and Tanzania.
Research and evaluation aims to assess whether the V&A programs in East Africa and South Asia function in different settings and whether productivity in reproductive health service delivery is improved. Not much is known about how V&A programs affect the operational efficiency of service-delivery organizations and whether they affect quality of care, service utilization, and RH behaviors and status at the population level. In the near future, the RH Vouchers Project will launch a Vouchers Resource Center at the Council’s Nairobi office to support information distribution and data archiving and develop Web-based tools for enhanced delivery.
Offsite link: RH Vouchers blog
Community-level impact of the reproductive health vouchers programme on service utilization in Kenya (abstract) (PDF)
Obare,Francis; Warren,Charlotte; Njuki,Rebecca; Abuya,Timothy; Sunday,Joseph; Askew,Ian; Bellows,Benjamin
Health Policy and Planning Published online ahead of print, 3 April
Publication date: 2012
Determinants of facility deliveries and use of antenatal care in Cambodia: Implications for universal versus targeted finance strategy
Bajracharya,Ashish; Dingle,Antonia; Bellows,Benjamin
Working paper
Publication date: 2012
Evaluation of the population-level impact of the maternal health voucher program in Uganda
Reproductive Health Vouchers Evaluation Team
Working paper
Publication date: 2012
Exploring the effectiveness of the output-based aid voucher program to increase uptake of gender-based violence recovery services in Kenya: A qualitative evaluation (abstract) (HTML)
Njuki,Rebecca; Okal,Jerry; Warren,Charlotte; Obare,Francis; Abuya,Timothy; Kanya,Lucy; Undie,Chi-Chi; Bellows,Benjamin; Askew,Ian
BMC Public Health 12(1): 426-
Publication date: 2012
Health expenditure of women using reproductive health services at public health facilities in Cambodia
Chhorvann,A.C.; Vonthanak,Saphonn; Bajracharya,Ashish; Bellows,Benjamin
Working paper
Publication date: 2012
Increase in facility-based deliveries associated with a maternal health voucher programme in informal settlements in Nairobi, Kenya (abstract) (HTML)
Bellows,Benjamin; Kyobutungi,Catherine; Mutua,Martin Kavao; Warren,Charlotte; Ezeh,Alex C.
Health Policy and Planning Published online ahead of print, 21 March
Publication date: 2012
Lessons from sexual and reproductive health voucher program design and function: A systematic review
Gorter,A.C.; Grainger,C.; Okal,Jerry; Bellows,Benjamin
Working paper
Publication date: 2012
The reproductive health vouchers program in Uganda: Summary of findings from program evaluation
Reproductive Health Vouchers Evaluation Team
Working paper
Publication date: 2012
Trends and determinants of facility deliveries and antenatal care use in Cambodia: Evidence from the recent increase in service uptake
Poster presentation at Regional Forum on Healthcare Financing, Phnom Penh, Cambodia
Bajracharya,Ashish; Dingle,Antonia; Bellows,Benjamin
Publication date: 2012
Evaluation of the impact of the voucher and accreditation approach on improving reproductive behaviors and RH status: Bangladesh (abstract) (PDF)
Rob,Ubaidur; Rahman,Md.Moshiur; Bellows,Benjamin
BMC Public Health 11(1): 257-257
Publication date: 2011
Evaluation of the impact of the voucher and accreditation approach on improving reproductive behaviors and status in Cambodia (abstract) (PDF)
Bellows,Benjamin; Warren,Charlotte; Vonthanak,Saphonn; Chhorvann,Chhea; Sokhom,Hean; Men,Chean; Bajracharya,Ashish; Rob,Ubaidur; Rathavy,Tung
BMC Public Health 11: 667-
Publication date: 2011
Evaluation of the impact of the voucher and accreditation approach on improving reproductive health behaviors and status in Kenya (abstract) (PDF)
Warren,Charlotte; Abuya,Timothy; Obare,Francis; Sunday,Joseph; Njue,Rebecca; Askew,Ian; Bellows,Benjamin
BMC Public Health 11: 117-
Publication date: 2011
The use of vouchers for reproductive health services in developing countries: Systematic review (abstract) (PDF)
Bellows,Nicole M.; Bellows,Benjamin; Warren,Charlotte
Tropical Medicine and International Health 16(1): 84-96
Publication date: 2011
Increase in facility-based deliveries associated with a maternal health voucher programme in informal settlements in Nairobi, Kenya
Presentation at the First Global Symposium on Health Systems Research, Montreux, Switzerland, 16-19 November
Bellows,Benjamin; Kyobutungi,Catherine; Mutua,Martin Kavao; Warren,Charlotte; Ezeh,Alex C.
Publication date: 2010
RH vouchers newsletter, August 2010 (PDF)
Population Council
Publication date: 2010
RH vouchers newsletter, December 2010 (PDF)
Population Council
Publication date: 2010
RH vouchers newsletter, March 2010 (PDF)
Population Council
Publication date: 2010
The use of vouchers for reproductive health services in developing countries: Systematic review
Presentation at the First Global Symposium on Health Systems Research, Montreux, Switzerland, 16-19 November
Bellows,Nicole M.; Bellows,Benjamin; Warren,Charlotte
Publication date: 2010
Using vouchers to increase access to maternal healthcare in Bangladesh (abstract)
Rob,Ubaidur; Rahman,Md.Moshiur; Bellows,Benjamin
International Quarterly of Community Health Education 30(4): 293-309
Publication date: 2010
Reproductive health vouchers news, December 2009
Population Council
Publication date: 2009
Project Stats
Location: Bangladesh, Kenya, Uganda, Cambodia, Tanzania
Program(s):
Reproductive Health
Topic(s):
Health care financing
Strengthening health systems
Duration: 11/2008 - 10/2013
Population Council researchers:
Ian Askew
Ashish Bajracharya
Benjamin Bellows
Ubaidur Rob
Charlotte Warren
Non-Council collaborators:
Action for Health
Bangladesh Ministry of Health and Family Welfare
Cambodia Ministry of Health
EPOS Health Management
German Development Bank (KfW)
Kenya Ministry of Public Health and Sanitation
PricewaterhouseCoopers
Tanzania National Health Insurance Fund
The World Bank/Global Partnership on Output-Based Aid
Uganda Ministry of Health
UK Department for International Development
US Agency for International Development
World Health Organization
Donors:
Bill & Melinda Gates Foundation
What's New
- Learn more about reproductive health vouchers by visiting the RH vouchers project page and blog maintained by Council program associate Ben Bellows. (more) (offsite link)
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