Evaluating Voucher-and-Accreditation Programs to Improve Maternal and Reproductive Health Service Delivery

The Council is building the evidence base on the role of maternal and reproductive health vouchers in improving service use, equity, quality of care, cost-effectiveness, and coverage in East Africa and South and Southeast Asia.

The Issue

A voucher that entitles poor women to subsidized maternity care and family planning services from accredited providers has the potential to increase access to quality services and to reduce inequities in access and use. Women’s eligibility to receive subsidized services through a voucher is assessed using a poverty-grading tool. Once accredited and contracted, providers are able to offer services in exchange for the vouchers, after which they are reimbursed at a negotiated rate that reflects the cost of service provision and a small but reasonable profit to motivate their participation in the voucher program.

The number of voucher programs is growing in low- and middle-income countries, and there is emerging evidence from the Council’s research and related efforts that vouchers can have a positive impact on maternal and reproductive health behaviors, use of services, and the health status of women.

The Progress

The Population Council is evaluating voucher programs in five countries—Bangladesh, Cambodia, Kenya, Tanzania, and Uganda—to generate evidence that will help governments and development partners decide whether to expand these programs, include additional services, or support different healthcare financing models.

The programs aim to increase access to services, including safe motherhood (pregnancy care, attended delivery, and postpartum care), STI treatment, family planning, post-rape care, and, in Cambodia, legal abortion services.

Using a variety of research and evaluation methods, Council researchers are evaluating whether women who receive vouchers are using more maternal and reproductive health services than women who have not received them; determining whether voucher programs are reaching their intended recipients; documenting improvements in the quality of care provided and the quality of health facilities; comparing their cost-effectiveness to routine care in the public sector; and measuring the scale of these programs as a fraction of the cost of the Ministry of Health budget and as a percentage of births nationally.

The Impact

The Council’s evaluations are producing important evidence about the strengths and weaknesses of maternal and reproductive health vouchers with different program structures, conditions, and at varying scale; measuring program impact; and increasing awareness among program managers, policymakers, and governments of the benefits and challenges of vouchers as an effective approach for achieving equitable, high-quality, low-cost healthcare coverage:

  • In Uganda, for example, Council research found that the proportion of facility-based deliveries grew over 22 months in communities exposed to vouchers while the proportion of facility-based deliveries remained largely unchanged in similar but unexposed communities. Based on these findings, the Ugandan government, the World Bank, and other development partners are expanding the program to reach more poor women in various parts of the country.
  • In Bangladesh, a pilot voucher program increased the proportion of women delivering in facilities from 3% to 20%, attending antenatal care from 50% to 89%, and seeking postnatal care from 10% to 59%.
  • The Cambodia reproductive health voucher program showed a significant net increase in uptake in long-term contraceptive methods among Health Equity Fund (HEF)-eligible women over 24 months, while there was no significant behavior change in control areas.

Through its evaluation, the Council is also developing standard performance measures of voucher programs that will be used to make routine comparisons within and between programs over time to help gauge where the greatest possible health impact is being achieved.

Principal Investigator

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Journal Articles (30)

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