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Program Critique reading is attached
What to Submit
Your submission should be a 2- to 3-page Word document. Also include a title page. Use 12-point Times New Roman font, double spacing, and one-inch margins. You should include a minimum of two sources. Sources should be cited according to APA style.
IHP 670 Module Six Program Critique Guidelines and Rubric
Overview
You will complete five program cri�que assignments in the course to support your work as you prepare for your final project. These assignments ask that you cri�que a program described
within an iden�fied ar�cle located in the module’s resources. These ar�cles were chosen because they relate to the module’s topics and demonstrate some common problems that programs
encounter. In each assignment, you will have the opportunity to cri�que certain program components, such as resources, ac�vi�es, outcome measures, use of feedback loops, assump�ons,
and external barriers. Once planners have iden�fied the details for each of the program components, they must step back and assess how those components can best operate within the
program’s environment. That involves considering concepts such as cultural competency, systems thinking, ethical prac�ce, and others. You will focus on these different concepts, in turn,
through the program cri�ques. As you develop your program cri�que skills, you will be asked to iden�fy areas that could be or need to be improved and offer recommenda�ons.
In this assignment, you will cri�que a health or healthcare program selected for you. It is the program cri�que reading in the Resources sec�on of the module. This is the only reading that can
be used for this assignment.
This assignment will help you examine ac�vi�es used to improve par�cipa�on in a sexual and reproduc�ve health program. Pay par�cular a�en�on to the ac�vity that was designed to
remove an external barrier to care. Focus your cri�que on elements such as the risks involved, the benefits or desired results, and the intended results achieved to evaluate the program’s
ability to adjust.
This program cri�que will help you plan for the risks and external barriers to your program and improve the program’s ability to adjust and adapt over �me.
Prompt
Write a program cri�que that examines a health or healthcare program intended to meet a specific health need.
Specifically, you must address the following rubric criteria:
1. External Barriers to Care: Describe why it is important to iden�fy barriers that impede an individual’s or a group’s access to care. Consider the following ques�on to guide your
response:
Why do you think the use of vouchers was effec�ve or ineffec�ve in achieving desired results?
2. Program Risks: Describe why iden�fying poten�al risks is important in program planning. Consider the
following ques�ons to guide your response:
What two risks did the program create?
What ac�ons would you take to minimize these risks?
3. Program Benefits: Describe what secondary benefits are achieved in addi�on to the desired results and their importance to stakeholders and the overall program. Consider the
following ques�ons to guide your response:
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Why is it important to appreciate these secondary benefits?
How would you let other program planners know about these secondary benefits?
4. Impact on Desired Results: Determine whether the planned ac�vi�es achieved the desired results for the program and why you feel they did or did not achieve these results. Consider
the following ques�on to guide your response:
How might the ac�vi�es be adjusted for improving the program’s desired results if the program were to run again in the future?
Note that all the claims in your deliverable should be evidence based. Your cita�ons should be from your independent search for evidence (not from the scenario, textbook, or module
resources) of credible sources and be current within the last five years. You are required to cite a minimum of one source overall. Refer to the Shapiro Library Guide: Nursing—Graduate
located in the Start Here sec�on of the course for addi�onal support. If you need wri�ng support, access the Online Wri�ng Center through the Academic Support module of your course.
What to Submit
Your submission should be a 2- to 3-page Word document. Also include a �tle page. Use 12-point Times New Roman font, double spacing, and one-inch margins. You should include a
minimum of two sources. Sources should be cited according to APA style.
Module Six Program Critique Rubric
Criteria Exemplary (100%) Proficient (90%) Needs Improvement (70%) Not Evident (0%) Value
External Barriers to Care Exceeds proficiency in an
excep�onally clear and
insigh�ul manner, using
industry-specific language
Describes why it is important
to iden�fy barriers that impede
an individual’s or a group’s
access to care
Shows progress toward
proficiency, but with errors or
omissions
Does not a�empt criterion 20
Program Risks Exceeds proficiency in an
excep�onally clear and
insigh�ul manner, using
industry-specific language
Describes why iden�fying
poten�al risks is important in
program planning
Shows progress toward
proficiency, but with errors or
omissions
Does not a�empt criterion 20
Program Benefits Exceeds proficiency in an
excep�onally clear and
insigh�ul manner, using
industry-specific language
Describes what secondary
benefits are achieved in
addi�on to the desired results
and their importance to
stakeholders and the overall
program
Shows progress toward
proficiency, but with errors or
omissions
Does not a�empt criterion 20
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Criteria Exemplary (100%) Proficient (90%) Needs Improvement (70%) Not Evident (0%) Value
Impact on Desired Results Exceeds proficiency in an
excep�onally clear and
insigh�ul manner, using
industry-specific language
Determines whether planned
ac�vi�es achieved the desired
results for the program and
why they did or did not achieve
these results
Shows progress toward
proficiency, but with errors or
omissions
Does not a�empt criterion 1
5
Ar�cula�on of Response Exceeds proficiency in an
excep�onally clear and
insigh�ul manner
Clearly conveys meaning with
correct grammar, sentence
structure, and spelling,
demonstra�ng an
understanding of audience and
purpose
Shows progress toward
proficiency, but with errors in
grammar, sentence structure,
and spelling, nega�vely
impac�ng readability
Submission has cri�cal errors in
grammar, sentence structure,
and spelling, preven�ng
understanding of ideas
10
Professional Sources Incorporates more than two
professional, current (within
the last five years) sources, or
use of sources is excep�onally
insigh�ul
Incorporates two professional,
current (within the last five
years) sources that support
claims
Incorporates fewer than two
professional, current (within
the last five years) sources, or
not all sources support claims
Does not incorporate sources 10
APA Style
Formats in-text cita�ons and
reference list according to APA
style with no
errors
Formats in-text cita�ons and
reference list according to APA
style with fewer than five
errors
Formats in-text cita�ons and
reference list according to APA
style with five or more errors
Does not format in-text
cita�ons and reference list
according to APA style
5
Total: 100%
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Grainger et al. International Journal for Equity in Health 2014, 13:33
http://www.equityhealthj.com
/content/13/1/33
RESEARCH Open Access
Lessons from sexual and reproductive health
voucher program design and function: a
comprehensive review
Corinne Grainger1, Anna Gorter2, Jerry Okal3* and Ben Bellows3
Background: Developing countries face challenges in financing healthcare; often the poor do not receive the most
basic services. The past decade has seen a sharp increase in the number of voucher programs, which target
output-based subsidies for specific services to poor and underserved groups. The dearth of literature that examines
lessons learned risks the wheel being endlessly reinvented. This paper examines commonalities and differences in
voucher design and implementation, highlighting lessons learned for the design of new voucher programmes.
Methodology: The methodology comprised: discussion among key experts to develop inclusion/exclusion criteria;
up-dating the literature database used by the DFID systematic review of voucher programs; and networking with
key contacts to identify new programs and obtain additional program documents. We identified 40 programs for
review and extracted a dataset of more than 120 program characteristics for detailed analysis.
: All programs aimed to increase utilisation of healthcare, particularly maternal health services, overwhelmingly
among low-income populations. The majority contract(ed) private providers, or public and private providers, and
all facilitate(d) access to services that are well defined, time-limited and reflect the country’s stated health priorities.
All voucher programs incorporate a governing body, management agency, contracted providers and target population,
and all share the same incentive structure: the transfer of subsidies from consumers to service providers, resulting in a
strong effect on both consumer and provider behaviour. Vouchers deliver subsidies to individuals, who in the absence
of the subsidy would likely not have sought care, and in all programs a positive behavioural response is observed,
with providers investing voucher revenue to attract more clients. A large majority of programs studied used
targeting mechanisms.
s: While many programs remain too small to address national-level need among the poor, large
programs are being developed at a rate of one every two years, with further programs in the pipeline. The
importance of addressing inequalities in access to basic services is recognized as an important component in
the drive to achieve universal health coverage; vouchers are increasingly acknowledged as a promising targeting
mechanism in this context, particularly where social health insurance is not yet feasible.
Keywords: Results-based financing, Demand-side financing, Sexual and reproductive health, Maternal health,
Voucher program, Social franchising, Poverty targeting, Social health insurance, Incentives, Subsidies
* Correspondence: jokal@popcouncil.org
3Population Council, Ralph Bunche Rd., PO Box 17643-00500, Nairobi, Kenya
Full list of author information is available at the end of the article
© 2014 Grainger et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited.
mailto:jokal@popcouncil.org
http://creativecommons.org/licenses/by/2.
0
Grainger et al. International Journal for Equity in Health 2014, 13:33 Page 2 of 2
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Dramatic gaps in health
Globalization is a shorthand term for dramatic economic
expansion and growing international interdependence
among high-income countries and a large set of post-
colonial, low-income countries since the 1980s. That con-
vergence also changes the concept of “developing country”
as low-income countries cross into the low-middle in-
come bracket. Yet as globalization has pulled millions
from poverty, it has also opened a widening equity gap
within countries in terms of income and health status.
There are particularly large gaps in healthcare access, and
often the poor and vulnerable do not receive the most
basic of reproductive health services [1].
Current health service provision in many low-income
countries does not meet public needs and among the
community of aid actors there is frustration with the
lack of results achieved by more traditional input-based
approaches, such as support for training, infrastructure,
drugs and supplies, and behaviour change communica-
tion. Many governments are aware of the low perform-
ance of their health systems and are ready to test new
approaches, particularly those which can target under-
served groups with priority health services, such as vou-
cher schemes. The proliferation in the number of voucher
schemes since 2005, and the dearth of literature which ex-
amines lessons learned from program design and imple-
mentation, risks the wheel being endlessly reinvented.
This paper examines commonalities and differences in
voucher design and implementation, and highlights les-
sons learned for the design of new voucher programmes,
based on a review of 40 programs.
Result-based financing
During the last two decades, donors and governments
have invested in alternative financing models where finan-
cial payments and other incentives are linked to outputs.
The umbrella term for these approaches is results-based
financing (RBF) [2], defined as “a cash payment or non-
monetary transfer made to a national or sub-national gov-
ernment, manager, provider, payer or consumer of health
services after predefined results have been attained and
verified. Payment is conditional on measurable actions be-
ing undertaken”. RBF includes a wide range of approaches
which vary according to, among other things, the objec-
tives, the remunerated behaviours (or indicators), the en-
tity receiving the reward and the type and magnitude of
the financial reward. The common denominator in all
these strategies is payment, in some form, for results as
opposed to exclusively financing inputs.
A standard categorization is to distinguish RBF schemes
that offer incentives on the supply side (supply-side RBF)
from those with an incentive structure primarily on the
consumer side (demand-side RBF), although in practice
the boundary between these categories is not clear cut.
This is illustrated in Figure 1 below. In a supply-side RBF
approach, incentives are paid to the provider based on
results reported on a (set of) performance target(s) or in-
dicator(s). Where incentives are linked to, say, increased
utilisation of services by a specific target group, this will
have an indirect impact on the demand-side as health pro-
viders put in place more or less successful measures to
reach their targets and earn incentives. In demand-side
RBF there is a more direct link between the payment of
incentives, the actions of the intended beneficiary and
the desired result. Vouchers are a demand-side RBF ap-
proach with a strong supply-side effect; the behaviour of
both provider and consumer is directly influenced by
the incentive.
Voucher schemes
Vouchers are commonly used to channel subsidies (from
governments and/or donors) to stimulate demand for pri-
ority health services among specific underserved groups.
Figure 2 illustrates the basic structure of a voucher
programme. Subsidies go directly to the consumer in the
form of a voucher – a certificate, coupon or other token –
which the consumer exchanges for the specified goods or
services from an accredited or approved health facility
(public or private). The provider then claims payment
for services provided. Vouchers are usually competitive
with multiple providers; however, they can also be non-
competitive, i.e. working with fewer providers of a single
type [3]. Most healthcare voucher programs have been
designed to increase access to one or more sexual and
reproductive health (SRH) services.
Although there are many variations in the design and
implementation arrangements of voucher programs, they
share a number of important characteristics: a funding
body (government and/or donors), a governance structure
that oversees the program, and an implementing body (e.g.
voucher management agency) that distributes vouchers to
target populations, approves and contracts facilities to pro-
vide services to voucher clients, and reimburses the facil-
ities for services provided.
Vouchers are proving to be an interesting approach to
overcoming barriers related to accessing SRH care for
the poor and other vulnerable groups. There is growing
evidence that vouchers promote equity in access to spe-
cific health services, can offer financial protection and
lead to improved quality of care; cornerstones of the
move towards universal health coverage. Two recent sys-
tematic reviews of the evidence of the impact of voucher
programs on a range of variables found robust evidence
that vouchers can increase utilization of health services,
and modest evidence that voucher programs both im-
prove the quality of service provision and effectively
target resources to specific populations [4,5]. Although
Demand side RBF
Health
facilities
Supply side RBF
Govt/ donor funding
Management
Agency
(Govt/Non-
Govt)
Clients
HEF cards/
Insurance
cards/
Vouchers
Claims
(
vouchers)
Contract
$
Services
Entitlement
(cards/
vouchers)
Govt/ donor funding
Contracting
Agency
(Govt/Non-
Govt)
Health
facilities/ health
managers
Results
data
$
Performance-based
financing
and contracting
Figure 1 Supply-side and demand-side results-based financing approaches.
Grainger et al. International Journal for Equity in Health 2014, 13:33 Page 3 of
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http://www.equityhealthj.com/content/13/1/33
these results were based on the review of relatively few
underlying voucher programmes, newly published and
newly discovered studies support these findings, and
provide new evidence that vouchers are effective at
targeting and enhancing equity [6-11]. There are very
few studies of the impact of vouchers on health status
or efficiency.
While recent documentation has focused on analysing
the potential impact of voucher programs, none of the
Figure 2 Key characteristics of voucher programs.
literature has attempted to draw out lessons learned for
the design of new programs. The review by Meyers
et al., [5] highlighted the fact that program managers of
current and future voucher programs would benefit from
a review of lessons learned when implementing voucher
programs. This paper presents a timely and comprehen-
sive review of voucher program design and implementa-
tion arrangements based on an analysis of documentation
on 40 different voucher schemes.
Grainger et al. International Journal for Equity in Health 2014, 13:33 Page 4 of 25
http://www.equityhealthj.com/content/13/1/33
The objective of the review was to analyse the design and
different implementation arrangements for voucher pro-
grams for SRH services.
Through extensive discussion among the group of au-
thors, all of whom are experts on voucher program design
and evaluation, we developed the following inclusion and
exclusion criteria for the review:
� The inclusion of all voucher programs for health
services which started distribution of vouchers
before 28 February 2011. The cut-off date for the
review was June 2011 and a period of at least three
months of operation was considered necessary in
order to look at the functioning of a particular
program;
� The inclusion of voucher programs which do not use
a physical voucher, but which function in all other
respects as a voucher program (e.g. targeting the
poor through the use of Below Poverty Line cards in
India);
� The exclusion of programs that use vouchers for
goods (condoms, pills, insecticide treated bed nets to
prevent malaria) as opposed to services. Design and
implementation arrangements differ considerably
between voucher programs for goods and voucher
programs for services. Voucher programs for goods
function more like social marketing programs;
� The exclusion of those voucher programs that are
operating in high income countriesa;
� The exclusion of programs where there is no
reimbursement to the facility or provider. These
include programs where a voucher is only used as a
marketing tool to attract clients to a facility, where
vouchers are used for referral services between
health facilities only, or where vouchers are used for
research (tracking of clients, data collection, etc.). It
also excludes conditional cash transfer programs
where there is no provider reimbursement payment
since these are pure demand-side programs which
do not provide incentives (and therefore do not
channel funding) to health service providers as in
voucher schemes.
Using the above inclusion and exclusion criteria, we
conducted a comprehensive review and compiled a list
of all voucher programs. The literature database devel-
oped through the DFID systematic review and which in-
cluded data up to October 2010 was used as the basis
[5]. We then used the same methodology to update this
database from April to December 2011 with: (i) searches
of bibliographic databases using specified key words (i.e.
voucher, coupon, certificate); (ii) a review by hand of the
grey literature; (iii) back checking of references for all
selected articles and documents: (iv) checking of organ-
isational networks and websites, as well as (v) extensive
networking and sourced information from key contacts.
The aforementioned review by Bellows et al. (2011)
identified 13 voucher programs, all providing SRH ser-
vices in developing countries. The review by Meyer et al.
(2011) identified 43 voucher programs, including the 13
programs of Bellows et al. and also including voucher pro-
grams for goods (e.g. insecticide treated bed nets) [4,5]. Of
the 43, a total of 21 programs fit the criteria for our com-
prehensive review, which also identified 19 additional pro-
grams giving a total of 40 programs.
The database on these 40 identified voucher programmes
was then enhanced through additional searches in order to
obtain more detailed information related to context, design
and implementation arrangements. Networking and cor-
respondence with key contacts was particularly useful in
identifying new programs and in providing program de-
scriptions (e.g. reports), tools (e.g. contracts, operational
manuals, vouchers), and other relevant material. A list of
published documents consulted, organised by country, is
included as
.
We developed a list of 120 program characteristics,
which were thought to be relevant for the design and im-
plementation of voucher programs through extensive dis-
cussions with voucher experts. The characteristics were
extracted from the literature, collected and input into an
excel database to facilitate analysis, for example summing
(e.g. type of voucher service, type of health service pro-
vider), defining averages (e.g. available budget), cross
analysis (e.g. type of management agency against type of
service providers contracted) and so on. These character-
istics were then grouped into five major categories related
to design and implementation of the voucher programs:
1. General aspects: size and geographical coverage,
statement of objectives, timeframe and financing;
2. Management and governance: structural aspects of
voucher programs such as governance, implementing
and/or managing entity and its relation to contracted
providers; role and participation of government;
3. Benefits and targeting: benefit and client policies
such as services covered, distribution strategies (i.e.
sold or freely distributed), and targeting approaches;
4. Providers: types of provider; competition; selection
and contracting; price of services and reimbursement
to providers;
5. Implementation arrangements: marketing, training,
voucher distribution, claims processing, monitoring
and evaluation, and fraud control.
In this paper, we describe the results of the analysis of
these five categories, looking at commonalities and differ-
ences and identifying the lessons learned for programmers.
Grainger et al. International Journal for Equity in Health 2014, 13:33 Page 5 of 25
http://www.equityhealthj.com/content/13/1/33
This systematic review of the literature relies on second-
ary published and unpublished literature. Ethics review
was therefore not necessary.
Results
General program characteristics: objectives, financing,
size and coverage
Forty voucher programs were identified in this compre-
hensive review (see Table 1); 22 are still active and 1
8
ceased to exist. Of the 18 programs that have ended, five
programs met their original objectives; five were studies
or pilots either taken over by or informing new pro-
grams; one program was incorporated into a Health
Equity Fund; and seven programs were unable to find
new funding, most of them belonging to the older pro-
grams developed during the 1990s.
A review of voucher program objectives generated a list
of reasons for choosing vouchers over an alternative ap-
proach. Nearly all programs address a combination of ob-
jectives with the most common being: increasing access to
priority services among underserved and vulnerable popu-
lations; accelerating the use of underutilized services; and
expanding provision of priority services through contract-
ing of private sector facilities (e.g. in countries where most
providers are private or where there are large gaps in pub-
lic service provision). Introducing choice for clients and
competition between service providers to drive quality im-
provements; and increasing transparency and verification
of service delivery are other secondary objectives men-
tioned in the literature. An overriding and implicit goal of
many voucher programs is that of preventing catastrophic
out-of-pocket payments for healthcare among the poor.
This is particularly relevant for maternal and newborn
health care where the potential treatment costs are un-
known when a woman arrives to deliver, and can be very
high for complicated cases.
The review also shows that vouchers can be used to
curb informal payments (e.g. Armenia) or to introduce
social health insurance capacity into the health sector
(e.g. voucher programs financed by the German Devel-
opment Bank, KfW, in Cambodia, Kenya, Tanzania and
Uganda). The longer-term stated objectives for the KfW-
financed voucher schemes is that, by introducing skills
that are relevant to social health insurance, vouchers will
help governments to develop their capacity to purchase
health services (accreditation, pricing, contracting, qual-
ity assurance, monitoring, claims processing and reim-
bursement) and to target subsidies to particular needy
populations. This is also true of voucher programs de-
signed after the cut-off date for our study, such as a ma-
ternal and newborn health voucher scheme in Yemen
being designed with support from the World Bank, which
explicitly supports a move towards the separation of the
roles of ‘purchaser’ and ‘provider’ of health services. This
is being achieved through capacity building of a semi-
autonomous voucher management agency as the pur-
chaser of a defined package of maternal, newborn and
reproductive health services from both public and pri-
vate sectors. The extent to which voucher schemes are
able to build this capacity with host-country govern-
ments needs to be closely monitored.
The authors did not find reference in the literature to
voucher programs where the original objectives of a pro-
gram were substantially changed. What is clear is that
voucher programs can and do adapt to changes in the ex-
ternal operating environment, such as changes in policies
on user fees, levels of provider autonomy, willingness of
the government to contract with private providers and so
on. There is also evidence that voucher schemes can be
adapted (and often expanded) to incorporate lessons
learned, as the success or failure of particular strategies
becomes clearer, and new funding agencies are attracted
with their own agendas. This is well illustrated by the pro-
gression of the voucher program in Uganda (See Uganda
Case Study below).
Uganda Case Study: Following a feasibility study in
2004, the KfW-financed Uganda voucher program issued
its first voucher providing access to STI diagnosis and
treatment (the Healthy Life voucher) in 2006. In 2008,
with joint funding by KfW and GPOBA, a safe mother-
hood voucher was added (Healthy Baby voucher) and the
scheme was expanded to become the Reproductive Health
Voucher Program (RHVP). While the STI voucher was ef-
fectively available to everyone via selected pharmacies lo-
cated in poorer socio-economic areas, the Healthy Baby
voucher was explicitly targeted at poorer clients identified
through door-to-door visits using a poverty assessment
tool. In 2011, with funding from USAID and DFID a fam-
ily planning voucher was added through a new scheme
(Saving Mothers, Giving Life) which used the same sys-
tems and processes set up for RHVP, but is piloting a
transport voucher, and expanded BCC activities to include
nutrition. Whereas to date the voucher schemes have all
worked exclusively with private providers (commercial
and not-for-profit), the government is currently working
with the World Bank to scale-up the voucher approach
nationally using a mix of public and private providers and
providing access to an expanded basket of services.
The majority of the voucher programs reviewed (see
Table 2) are in Asia (31 out of 40). In Asia, India has (or
has had) nine voucher programs, followed by Pakistan (5),
Cambodia (5) and Bangladesh (4).
Over a quarter of the programs were initiated by a
donor, often directly engaging with government, and
mostly in Asia (see Table 3). Governments, including state
governments in India, initiated eleven programs, four in
close collaboration with donors. Interestingly all of the
government-initiated programs are in Asia. Outside Asia,
Table 1 Details of the 40 identified voucher programs
Country Initiated by Years1 Reason to use vouchers Services Type providers Type VMA Size VP
2
1 Armenia3 Government 2008-ong4. Curb informal payments SMH, CD5 Public (few), private Government Large
2 Bangladesh 1 Government/donor SWAp 2006-ong. Increase use priority services SMH All three, most public Gov./WHO Large
3 Bangladesh 2 Research center – ICDDR,B 2006-2008 Op Research to test vouchers for
skilled birth attendance
SMH Only private University Small
4 Bangladesh 3 Intern. NGO – Pop Council 2007-2008 Op Research to test vouchers to improve
up-take of MNCH services among poor
rural women
SMH All three sectors NGO Small
5 Bangladesh 4 Social Franchise – MSI 2007-2010 Increase use priority services SMH All three sectors SFO Small
6 Cambodia 1 Donor – BTC 2007-2010 Expand HEF to Health Centers SMH Only public NGO Small
7 Cambodia 2 UN organization – UNFPA 2008-2010 Expand HEF to Health Centers SMH, FP, SA, STI Only public NGO Small
8 Cambodia 3 Donor – USAID 2009-ong. Expand HEF to Health Centers SMH Only public NGO Small
9 Cambodia 4 Donor – KfW 2011-ong. Introduce social health insurance skills SMH, FP, SA All three sectors Private/NGO Large
10 Cambodia 5 Social Franchise – MSI 2010-ong. Increase use at trained facilities FP All three sectors SFO Small
11 China 1 Government/World Bank 1998-2001 Increase use priority services SMH, CD Only public Gov./Project Medium
12 China 2 Government/World Bank 2005-2007 Increase use priority services SMH, RTIs Only public Gov./Project Small
13 India-Agra, UP Donor – USAID/State Gov. 2007-ong. Contract private sector/build PPP SMH, FP, STI/RTI only private Government Small
14 India-Kanpur, UP Donor – USAID/State Gov. 2008-ong. Contract private sector/build PPP SMH, FP, STI/RTI NGO and private NGO Medium
15 India-Jharkhand Donor – USAID 2009-2011 Contract private sector/build PPP FP Only private NGO Small
16 India-Uttarakhand Donor – USAID/State Gov. 2007-ong. Contract private sector/build PPP SMH, FP NGO and private Government Medium
17 India-Gujarat State Government 2005-ong. Contract private sector/limited public
capacity
SMH Only private Government Large
18 India-Rajastan Local NGO 2003-2006 Contract private sector/limited public capacity
SMH Only private NGO Small
19 India-Kolkata Donor (Gates)/NGO 1999-2003 Contract private sector/limited public capacity SMH, FP, STI/RTI, CD Only private NGO Small
20 India-Delhi State Government 2008-ong. Contract private sector/limited public
capacity
SMH Only private Government Medium
21 India-Haryana State Government 2006-2011 Contract private sector/limited public
capacity
SMH Only private NGO Small
22 Indonesia Government/World Bank 1998-2004 Contract private sector/limited public capacity SMH, FP Only private Gov./Project Medium
23 Kenya 1 Donor – KfW 2006-ong. Introduce social health insurance skills SMH, FP, GBV All three sectors Private Large
24 Kenya 2 Intern. NGO – Popcouncil 1997-2010 Contract private sector/preference of target
population
SRH care for youth Public (few), private NGO Small
25 Korea Government 1964- ~1985 Contract private sector/facilitate M&E FP Public (few), private Government Large
26 Madagascar Social Franchise – PSI 2005-ong. Increase use by poor at franchise clinics SRH care for youth Only private (SF) SFO Small
27 Myanmar Social Franchise – PSI 2005-ong. Increase use by poor at franchise clinics FP, STIs Only private (SF) SFO Small
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Table 1 Details of the 40 identified voucher programs (Continued)
28 Nicaragua-Sex Workers Local NGO 1996-2009 Contract private sector/preference of target
population
STIs All three sectors NGO Small
29 Nicaragua-adolescents Local NGO 2000-2005 Contract private sector/preference of target
population
SRH care for youth All three sectors NGO Small
30 Nicaragua-
Cervical
Cancer
Local NGO 1999-2009 Contract private sector/preference of target
population
Cervical Cancer scr. All three sectors NGO Small
31 Pakistan (MSI) Social Franchise – MSI 2008-ong. Increase use by poor at franchise clinics FP Only private (SF) SFO Small
32 Pakistan-DG Khan Social Franchise – PSI 2008-2009 Increase use by poor at franchise clinics SMH Only private (SF) SFO Small
33 Pakistan-Jhang Social Franchise – PSI 2009-ong. Increase use by poor at franchise clinics SMH Public (few), private SFO Small
34 Pakistan-Charsadda Donor-KfW (PSI
implemented)
2010-2011 Introduce social health insurance skills SMH Public (few), private SFO Small
35 Pakistan-Sehat
Sahulat Card
Local Government 2009-ong. Contract private sector/limited public
capacity
SMH public (few), private Private Small
36 Sierra Leone Social Franchise – MSI 2009-ong. Increase use by poor at franchise clinics SMH, FP NGO and private SFO Small
37 Taiwan Government 1964- ~1985 Contract private sector/facilitate M&E FP Public (few), private Government Large
38 Uganda (KfW/GPOBA) Donor-KfW and GPOBA
(MSI implemented)
2006-ong. Introduce social health insurance skills STIs, SMH, FP NGO and private SFO Large
39 Uganda (University) Makerere University 2009-2011 Research study to assess vouchers for
Institutional Delivery & transport
SMH All three sectors University Small
40 Vietnam-Sex Workers Int. NGO-Pathfinder 2009-2009 Contract Private Sector/preference of target
population
STI Only private Government Small
Notes: 1Voucher Programmes that are active up to December 2011; 2Size VP indicates the annual budget in three categories: large (greater than $1 million), medium ($250,000 to $1 million), and small (less than
$250,000); 3Rows in bold are active programs; 4Ong (on-going) = continued into 2012; 5CD = Childhood diseases.
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Table 2 Number of voucher programs in each region and
country
Regions Voucher programs Countries
Latin America 3 Nicaragua (3)
Africa 6 Kenya (2), Uganda (2),
Sierra Leone, Madagascar
Asia 31
• West Asia 1 Armenia
• South Asia 18 India (9), Pakistan (5),
Bangladesh (4)
• East Asia
and Pacific
12 Cambodia (5), China (2),
Indonesia, Korea, Myanmar,
Taiwan, Vietnam
All 40
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the two programs classed as large were initiated by the
German Development Bank (KfW) in Kenya and Uganda,
and the rest are small voucher programs that have
been started by social franchising organizations, Non-
Governmental Organizations (NGOs) and research in-
stitutes, nearly always with donor support.
Figure 3 shows the number of voucher programs that
were active in a particular year. The figure illustrates
clearly the huge increase in the number of voucher pro-
grams, particularly since 2004. The first two schemes were
developed in 1964 (Taiwan and Korea) with the objective
to lower the fertility rate through accelerating the use of
family planning. After a small pilot in each country, the
voucher programs were quickly scaled nationwide and
continued until the mid-1980s when fertility had reached
replacement level.
Between the late 1990s and 2004 only a handful of
programs were initiated (six small programs and two
medium-sized projects in China and Indonesia), coin-
ciding with a period when bilateral aid was firmly fo-
cused on direct support to governments. In 2005, the
number of voucher programs began to increase and
Table 3 Type of organization that initiated the voucher
program
Initiated by Voucher programs Observation
Donor 11 9 in Asia and 2 in Africa
Government 11 All in Asia, 4 in collaboration
with donors
SFO 8 6 in Asia, 2 in Africa
NGO 7 3 in Asia, 1 in Africa, 3 in
Latin America
Research institute 2 1 in Asia (Bangladesh), 1 in
Africa (Uganda)
UNFPA 1 1 in Asia (Cambodia)
All 40
Social Franchising Organizations also started to intro-
duce vouchers to increase use of SRH services by poor
and disadvantaged populations at franchised clinics, ac-
counting for a significant part of the more recent increase
in voucher schemes. The number of active voucher pro-
grams in 2011 (Figure 3) includes eight voucher programs
that were initiated after the cut-off date of this review.
Eight of the voucher programs can be categorized as
‘large’ in size with a budget of over US$1 million per
annum (see also Figure 3). Large voucher programs that
are on-going at the time of writing include the KfW-funded
voucher programs in Cambodia, Kenya and Uganda, the
Armenian Obstetric Care State Certificate (OCSC) pro-
gram, the Indian scheme in Gujarat, and the large voucher
program in Bangladesh (also known as the Demand Side
Financing or ‘DSF program’). The earlier programs in
Taiwan and Korea also had very large budgets that var-
ied from year to year and were national in scope.
Only three voucher programs have been implemented
nationally: Armenia, Taiwan and Korea. The voucher pro-
gram in Gujarat, India, which targets the population with
a Below-Poverty-Line or BPL card, is implemented state-
wide and, with a population of some 60 million people,
Gujarat is larger than Armenia, Taiwan or Korea. An esti-
mated budget of some US$7 m per year also means that
this has been one of the largest voucher programs. The
other programs identified as ‘large’ in this review cover
only a fraction of the general population: the DSF program
in Bangladesh covers around 10% of upazilas or sub-
districts, and the large KfW-funded voucher programs in
Cambodia, Kenya and Uganda target the poor, delivering
approximately 3% of all births nationally and operating in
between five and 20 districts depending, among other
things, on how long they have been in operation. The
World Bank is currently supporting the Government of
Uganda in the design of a nationally scaled voucher pro-
gram (see Uganda case study) with multiple funding
sources (mostly multilateral and bilateral donors), as well
Figure 3 Number of active voucher programs in each year
1964–2011.
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as a further large voucher program in the Republic of
Yemen.
Four voucher programs are of medium size (budgets
of between US$250,000 and US$1 million per year), and
nearly three quarters (28) of the programs are small,
with budgets of less than US$250,000 per year, reflecting
both the number of pilot interventions and the recent
proliferation of small but growing voucher programs at-
tached to social franchise networks. These have been
introduced by franchising organisations, such as Marie
Stopes International (MSI) or Population Services Inter-
national (PSI), with the aim of growing the market for
first time service users (who may become paying clients
over time) and of meeting equity-related objectives and
conditions, often attached to donor funding.
Management and governance
There are different management structures among the
programs reviewed, largely due to the type of initiating
agency (i.e. whether government or non-government),
and the need for programs to be tailored to the context
in which they are designed (e.g. type of providers avail-
able or willingness of government to work with the
private sector).
Programs initiated by donors are sometimes managed
by the government, but mostly by a private agency (profit
or not-for-profit) as the so-called voucher management
agency, which is responsible for implementation (identify-
ing, contracting and monitoring providers, distributing
vouchers to intended beneficiaries, and organising pay-
ments for verified service delivery). Most managing agen-
cies are assigned; only in two cases has this function been
tendered, e.g. in the KfW-funded programs in Kenya
and Cambodia where this was related to donor procure-
ment rules. The governing body, which oversees the
program, is mostly a steering committee or project ad-
visory group, with representatives from government, do-
nors and other stakeholders, often fully independent
from the managing agency.
In government-initiated programs, the agencies re-
sponsible for implementation and governance are often
both from the public sector (i.e. Ministry of Health). In
these situations, the governing body is often at central
or provincial level while the management function is at
lower levels. For example, in Gujarat the State Health
Directorate oversees the program while project manage-
ment units at the district level are implementing the
program and also act as the managing agency.
Programs initiated by NGOs or social franchising or-
ganisations and research institutes, which are mostly fi-
nanced by donors, are all managed by the organizations
themselves. Hence the governance structure is also the
same as the managing agency. In four of the ten voucher
schemes managed by social franchising organisations,
providers are restricted to the franchise network, which
could limit competition and lead to gaps in coverage.
The argument for a strong governance structure gets
more compelling as the funding for a voucher program in-
creases and the program expands, with the attendant op-
portunities for fraud. As stewards of the health sector, it is
important that the government has oversight of any large
health financing intervention, particularly those that target
the poor. This has been seen in both Kenya and Cambodia
where management structures have been adjusted to ar-
ticulate more clearly the responsibility of government in
overseeing the voucher schemes (see Governance Case
Study, Kenya below).
While the potential for fraud is an often-cited concern
for donors, a strong management information system
(MIS) and a robust claims processing system, verification
of results (often by an independent agency), monitoring
and enforcement of annual contracts with providers, and
strong checks and balances employed by the managing
agency, may account for the relatively low incidence of
fraud reported in the literature (although fraud may well
be under-reported). The most common types of fraud
encountered include: providers purchasing vouchers and
seeking reimbursement for fictitious clients; distributors
or clients forming an alliance with providers without
provision of actual services; providers handing in false
claims; service providers inflate complications treated
and claim for higher amounts; and the providers char-
ging additional fees from voucher holders.
Those voucher schemes managed by a third party man-
aging agency, such as the large KfW-financed schemes in
Kenya and Cambodia, have strong anti-fraud protection
measures built into the design, based on a twin strategy of
analysing trends in voucher distribution and claims made,
and on verifying samples of claims (randomly generated
by the program management information system) at the
level of the voucher service provider and at the benefi-
ciary’s home. Knowledge of ‘what works’ in fraud protec-
tion is being built into the design of new voucher schemes
(i.e. in Yemen and Moçambique).
Other common checks and balances reported to coun-
teract fraud include the use of unique serial numbers,
and use of spot checks. These mechanisms, if employed
carefully, will counteract all types of fraud listed above.
It should also be remembered that, even though fraud is
notoriously difficult to quantify, all health systems, how-
ever the financing of services is organized, experience a
degree of fraud [11].
In all large programs, contracts enable the managing
agency to exclude providers from the program or to enact
other sanctions for fraudulent behaviour (e.g. the KfW-
financed programs in Cambodia, Kenya and Uganda, and
the national scheme in Armenia). Where contracts are not
well enforced, stakeholders are able to adapt the scheme to
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suit their own needs such as in the Chiranjeevi Scheme in
Gujarat where a flat reimbursement for every 100 deliveries
regardless of the number of C-sections or complicated
cases led to private obstetricians referring complicated
cases to public sector facilities in order to reduce costs.
Independence and autonomy of the managing agency
has often been cited as an important feature for the ‘ideal’
governance and management structure to prevent fraud
(because the body overseeing the program can independ-
ently sub-contract quality assurance or verification and
has more leverage over the managing agency than when
both bodies are from the same organisation). However,
our review shows that both forms are functional among
the voucher programs analysed and none of the literature
examined the effect of independent governance structures
on the functioning of the program in terms of reducing
fraud or increasing the quality of care provided.
Perhaps more important is the split between purchaser
and provider; that is the managing agency contracts pro-
viders not belonging to its own organisation, in order to
ensure transparency, widen choice, increase efficiency and
counteract fraud. Although in nearly all voucher programs
there is a split between purchaser and provider (i.e. in
37 of the 40 programs analysed the managing agency
contracted providers from a different organisation and/or
sector), there are also exceptions such as the large voucher
program in Bangladesh and two programs in China where
the managing agency and large majority of providers be-
long to the public sector, but which nonetheless functioned
well. However, in these programs, there are still checks and
balances in place that provide a degree of management in-
dependence (in Bangladesh this results from a special
programme management unit set up for management of
the scheme, and in China the WHO financed supervisors
within the state voucher management unit).
Governance Case Study, Kenya: Initiated in 2005, the
KfW-financed project in Kenya (RH-OBA project) will
enter its fourth phase in 2014. The Government of Kenya
(GoK) has begun to take on a more significant role with
regard to both financial contributions to, and governance
of, the program. In 2011, the oversight of the program
moved from the National Coordinating Agency for Popu-
lation and Development, a semi-autonomous agency, to
the Ministry of Public Health and Sanitation (MoPHS),
which has since merged with the Ministry of Medical Ser-
vices (MoMS). Other key changes have included constitut-
ing a Program Management Unit (PMU) in government
and establishing linkages with sub-national health man-
agement systems, with the aim of building sustainability.
The new State Department of Health, the National Hos-
pital Insurance Fund (NHIF) and KfW together sit on the
Steering Committee. Throughout this time, the managing
agency contract has remained with PricewaterhouseCoo-
pers, responsible for the operational management of the
scheme. During Phase III, the GoK has increased its con-
tributions to the program, and significant efforts will be
made in Phase IV to further build the institutional and
technical capacity of the PMU in health financing and to
adapt the design of the voucher scheme to the 2013 policy
on free maternal health services.
Provider autonomy
The issue of provider autonomy is not explored in detail
in the literature. It is clear that the optimum model is
for providers to have autonomy, not only to reinvest
voucher payments on quality improvements, staff incen-
tives and other activities but also to organise and man-
age services so as to attract clients in the target group
more efficiently and effectively. While provider auton-
omy is the norm when private providers are contracted
into voucher programs, there are varying degrees of au-
tonomy with participating public and also not-for-profit
providers. No public voucher service provider reported
having full autonomy to organise service provision accord-
ing to the requirements of the voucher program, i.e. in-
cluding the ability to hire and fire medical staff. Voucher
programs can provide a framework for moving towards
greater provider autonomy, at least in terms of reinvesting
voucher income, and this has been seen in the case of
the KfW-financed voucher program in Kenya where
some public sector voucher service providers have been
able to invest a growing proportion of their voucher in-
come in improving service quality, due to the support
and influence of the managing agency.
Voucher benefits and clients (demand side characteristics)
Currently voucher programs provide access to only a
limited ‘basket’ of services, with 26 out of 40 programs
providing only one type and 7 providing two types of ser-
vice – often a combination of safe motherhood (SMH)
and Family Planning (FP) services. It is worth noting,
however, that one ‘type’ of service may in fact be a package
of safe motherhood services (including antenatal and post-
natal care, normal and complicated deliveries, and post-
natal FP) or in the case of programs in Armenia and
China a package of child health services.
A further 7 programs have expanded to provide three or
four different service types, reflecting on-going discussions
about expanding access to a broader range of voucher ser-
vices. Two-thirds of voucher programs provide SMH ser-
vices, and almost half provide FP services (Figure 4). Other
types of service provided through vouchers include diagno-
sis and treatment of sexually transmitted infections, child
health, sexual and reproductive services for young people,
safe abortion, cervical cancer screening and gender-based
violence recovery services. As voucher schemes introduce
more services they begin to resemble insurance schemes.
In Tanzania, vouchers are used to enrol (and subsidise)
SMH
services
Family
Planning
RTIs/STIs
Child
Diseases
SRH care
for youth
Safe
Abortion
Cervical
Cancer
screening
Gender
Based
Violence
VPs 28 16 9 3 3 2 1 1
0
5
10
15
20
25
30
Figure 4 Type of services provided and number of programs providing that particular service (of 40 programs reviewed).
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poor pregnant women in a temporary health insurance
providing access to a broad package of services, while their
families receive subsidised entry to community health in-
surance, illustrating further the link between vouchers and
insurance schemes.
All on-going programs provide free access to services
at the point of delivery and the majority also distribute
the vouchers for free. Only the KfW-funded programs in
Uganda and Kenya and the social franchising programs
charge a nominal fee for the voucher.
Once established, voucher programs can be used as a
conduit for additional non-medical benefits such as trans-
port, food and cash. Some 10 programs paid for transport
costs in addition to the cost of health services, almost all
of them in Asia where the cost of transport is a significant
barrier to the uptake of health services (Bangladesh,
Cambodia, India and Pakistan). The only exception is a
small voucher program in Uganda implemented by the
University of Makerere which researched the effect of
transport vouchers combined with SMH vouchers, and
found that the transport vouchers were largely responsible
for the huge increases in the utilization of SMH services
[12]. It is interesting to note that in the KfW-financed
scheme in Kenya, some providers in rural areas pay for
transport to the facility out of voucher reimbursement in-
come, demonstrating the importance of transport costs as
an access barrier.
Of the on-going voucher programs, nearly all use some
form of targeting to channel resources to a priority group
(see Table 4). They do this through a combination of
mechanisms, most commonly a poverty assessment tool
in the form of a questionnaire, a pre-existing poverty iden-
tification system such as those used in India (the BPL
card) or Cambodia (the Poor ID Card) or geographical
targeting of areas identified as ‘poor’. The one current
exception is the national program in Armenia, which is
untargeted and uses the voucher approach to provide ac-
cess to priority services for the whole population through
a public private partnership framework, similar to the
early programs in Korea and Taiwan. Debate is on-going
about the relative benefits of means testing, which can be
expensive and time consuming and geographical targeting,
which is less accurate but with much lower costs [13].
The voucher program in Taiwan illustrates the flexibil-
ity of the approach in adapting to changes in the operat-
ing and policy environment. By altering a few aspects of
the program, the government could continue to channel
resources to priority services, but in the context of rising
program costs and decreasing resources, the voucher
moved from universal targeting to a system where the
subsidy was targeted only to those less able to pay. The
subsidy was reduced or even stopped for the better-off,
without major effects on program performance [14].
Vouchers have a marketing and health education func-
tion that is relevant in contexts where a change of health
seeking behaviour is sought because populations are un-
familiar with, or reluctant to use specific services. Vouchers
provide information through marketing and voucher distri-
bution strategies on why the services are important and
where to find them, actively inviting clients to use the ser-
vice. The marketing function of vouchers has been found
to be a key aspect of voucher programing, particularly
where vouchers are distributed door-to-door or through
community meetings, enabling distributors to talk to pro-
spective clients and answer questions (i.e. the KfW-funded
voucher schemes in Cambodia, Kenya and Uganda, and
the vouchers attached to SF schemes managed by MSI and
PSI in Pakistan). Local launch events and community
meetings, posters and pamphlets distributed by the man-
aging agency are some of the marketing activities seen in
the literature and we also found mention of 8 voucher
schemes that used radio and/or TV mostly focused on the
launch of a program.
While most programs use a physical voucher, i.e. a
booklet or coupon, some make use of existing poverty
identification schemes (see above) and two use ‘virtual’
Table 4 Targeting characteristics of the 40 voucher programs
Targeting mechanisms Yes Observation
Using means testing (MT) with or without other forms of targeting 23
• Use only means testing (MT) 18 5 VPs in India use a BPL card, 3 in Cambodia use a poor card, others
mainly use questionnaires, but 2 VPs in China used community-based
participatory approaches to identify the poor
• Use MT in combination with geographical targeting (GT) 3 GT usually used to identify poor rural or slum areas, questionnaires (MT)
in urban or peri-urban areas
• MT for SMH and FP services and universal targeting for Safe
Abortion and GBV
2 The KfW funded voucher programs used universal targeting for specific
services: Cambodia (safe abortion), Kenya (GBV services) and MT for others
Using only geographical targeting 14 A range of VPs in many countries targeted at areas identified as poor
such as rural areas (i.e. Nicaragua) or slums (i.e. India) or vulnerable
groups in poor areas (adolescents, sex workers)
Using universal targeting 3 Armenia, Taiwan, Korea (Taiwan and Korea moved to MT at a later stage)
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vouchers where services which may be stigmatizing such
as gender based violence recovery or abortion services
are marketed to the beneficiary group but the vouchers
are maintained at the provider and used for claims pro-
cessing as usual. The paper voucher has a number of
functions including providing information about the ser-
vice and where it can be obtained; acting as evidence for
the client and for the clinic that he or she has the right
to receive the services for free, thereby helping to pre-
vent informal payments; and acting as a data collection
form and paper trail for monitoring and evaluation. It is
believed that the voucher itself acts as a sort of personal
invitation, empowering its holder to access the services,
and this aspect of voucher programming would benefit
from research.
Although this was not the case among programs in
the current review, there is now a growing interest in
using electronic or e-vouchers that use SMS codes sent
by mobile phone or other handheld device (i.e. MSI in
Madagascar and Ethiopia, Chamganka in Kenya). With
mobile phone penetration rates rising and already close
to 90 % in some low-income countries [15], the use of e-
vouchers will doubtless increase.
Providers (supply side characteristics)
Providers participating in voucher schemes come from
different sectors: private, NGO (including facilities man-
aged by faith based organizations or social franchising
organisations) and public sector. In 14 voucher programs
only private sector facilities participated (Figure 5) and
half of these are in India where vouchers are routinely
used to fill gaps in public provision of priority health ser-
vices, such as safe and institutional deliveries.
The optimum number of providers in a voucher pro-
gram should be the number of providers that will both
ensure quality of service provision and access to services
for a target population, while enabling providers to earn
sufficient income through increased client load to attract
and keep them in the program.
Of the 40 schemes analysed, there are ten voucher
programs that contract or have contracted facilities from
all three sectors (public, NGO, and private). Seven pro-
grams provide services through a combination of public
and private-for-profit providers, although the actual num-
ber and role of public providers in these programs is lim-
ited due to the lack of available public sector facilities e.g.
the large, countrywide programs in Armenia, Korea and
Taiwan). Government policies and strategies influence the
selection of providers and in five voucher programs only
public service providers were contracted, due to govern-
ment reluctance to contract other types of provider (e.g.
Cambodia) and/or because private providers were not
available (e.g. China). Four voucher programs contract a
combination of NGO and private facilities: two managed
by Marie Stopes (Uganda and Sierra Leone) and two
funded by USAID in India.
Providers are usually selected according to compliance
with minimum quality standards and/or location. Data
were incomplete for this variable, but the authors found
that documentation for around half of the 40 programs
referred to provider selection based on location (i.e. vicinity
to a slum) and/or quality (i.e. signal functions). Vouchers
are increasingly recognized as presenting an opportunity to
introduce and improve accreditation processes and to as-
sist in developing capacity both to measure and maintain
the quality of health services, as evidenced in two new vou-
cher programs in Yemen, which are aligned with govern-
ment quality assessment and assurance procedures.
All voucher programs sign contracts or develop Memo-
randa of Understanding (MOU) with providers and these
agreements should form the basis for monitoring, fraud
control and quality assurance. Contracts typically include a
description of the services to be provided, the payment
schedules and issues related to monitoring, evaluation,
fraud control and disputes. Medical protocols and quality
criteria are also often included. With the exception of the
programs in Nicaragua, the authors found many references
in the literature to poor contracting (i.e. lack of detail) and
Only private All 3 sectors
Public (few),
private
Only public Private, NGO
VPs 14 10 7 5
4
0
2
4
6
8
10
12
14
16
Figure 5 Type of providers in the 40 voucher programs (VP).
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poor enforcement of contracts, which lead to less than op-
timal performance and quality of service provision.
Successful contracting with private providers can in-
crease the MOH’s interest, enhance local ownership, and
also stimulate public providers to raise the quality and
client-friendliness of their services. This is the case in
Uganda (see Uganda Case Study above), where after six
years of contracting with only the private sector, the gov-
ernment is currently considering how to take the vou-
cher program to scale nationally with a mix of public
and private providers.
The role of competition in voucher programs is one of
the least understood areas. There are two principal ways
in which competition works in voucher programs: among
providers to join the program at the approval process (and
to a lesser extent to remain in the program at contract re-
newal stage); and competition among providers to attract
clients into their facilities. In areas where there are few
providers (rural areas for instance), providers may com-
pete ‘for the market’ as opposed to within the market,
adapting their services to suit the needs of potential new
clients who might otherwise not use a service at all.
Although more than half of the programs were judged
by the authors to have strong competition between pro-
viders (defined as facilities contracted from more than
one sector or sufficient facilities from a single sector that
likely improved clients’ choice) this has not been moni-
tored, either through external research or internal program
monitoring. In theory, voucher programs with greater
competition between providers should be more effective
with lower prices and better quality. However, there are ex-
amples of functioning voucher programs where only public
sector facilities are contracted and further investigation is
needed to compare and contrast the role of competition
between these types of program.
As we have seen, the defining features of a voucher pro-
gram are: a governing body, a management agency or
managing agency, contracted providers which receive a
reimbursement payment according to services provided,
and a target population. There are, however, many dif-
ferent configurations with regard to both the nature and
type of governing body, management agency, providers,
benefits and target population.
Despite these different configurations, all voucher pro-
grams provide incentives to consumers, who use the
voucher and transfer the incentives to the provider. The
ultimate objective is a change in behaviour, not only of
the consumer but also of the provider and this does not
differ between programs. The means of achieving such
behaviour change is the incentive structure on both the
demand- and supply-side, which is perhaps the most rele-
vant structural feature of the voucher approach, overriding
differences in design and implementation arrangements.
In all programs reviewed a positive response is observed,
with providers responding better to the clients and invest-
ing voucher revenue to make their facility more attractive,
and consumers changing their health seeking behaviour to
access services which they were not previously using.
The review illustrates that all voucher programs aim
to increase utilization of a priority service; sometimes
for the general population where underutilization is
widespread, but mostly by poor or under-served groups
where the uptake of critical services is lower than na-
tional or regional levels. The focus on the poor or other
vulnerable groups is intended to stimulate care seeking
by individuals, who in the absence of the voucher would
likely have not sought care. There would be little value
in giving subsidies to individuals who would use the fa-
cility services regardless.
Looking at the range of objectives of the voucher pro-
grams under review, it is clear that vouchers are success-
fully used to address tiered or multiple objectives, such
as increased service utilization for a particular service or
set of services, leveraging of private sector provision (in
many cases to fill gaps in public provision), and targeting
of a particular group, e.g. in Gujarat where the voucher
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http://www.equityhealthj.com/content/13/1/33
scheme enables free access by poor women to private
obstetricians for institutional delivery.
Unsurprisingly perhaps, the stated objectives of vou-
cher schemes differ according to who initiates, finances
and is responsible for them, and programs initiated by
donors often have a wider health sector agenda, such as
KfW’s aim to encourage countries towards the introduc-
tion of social health insurance or USAID’s focus on
vouchers as a gateway to building public private partner-
ships. In Cambodia, vouchers are used to extend the reach
of the Health Equity Funds to lower levels of the health
system (health center level) and are also used as a mechan-
ism to verify that the client actually used the services [16].
It is also important to note that the majority of the
programs (35 out of 40) use vouchers to enable contract-
ing of the private sector. Vouchers make it feasible to
contract private providers, because they enable provider
registration, quality assurance, monitoring and tracking
of payments. This is particularly relevant in the absence
of national or sector-specific public private partnership
(PPP) policies or strategies, and may provide a useful ex-
ample to government (including at the local level) of
contracting-out service provision. Where there is very
little public service provision (e.g. Taiwan, Korea and
Armenia), vouchers are or have been used both to channel
subsidies to specific groups, and to control private pro-
viders (e.g. curb informal payments, which is an explicit
objective of the Armenia Health Certificate Program). Im-
portantly, vouchers provide a means of enabling govern-
ments to leverage the private sector capacity to meet
public health goals such as the MDGs (i.e. Kenya, India
and the newly scaled-up program in Uganda).
Most voucher programs seek to address the existing
poor-rich inequities in access to life saving services, such
as safe motherhood and family planning. While evidence
is growing that vouchers can and do improve equity (in
that they lead to greater increases in utilization among
the poor than among the non-poor) this is an important
area for further research. The capacity of vouchers to
target a particular group is possibly the most important
advantage when compared to other RBF approaches. In
Asia where a majority of people, including the poor, fi-
nance their health care through out-of-pocket payments,
usually in the private sector and even in the context of
free public health service provision, this enables subsid-
ies to follow those clients who most need them, thus
helping to avoid catastrophic payments associated with
certain high cost services such as Caesarean-sections for
complicated deliveries.
Because voucher programs can be implemented using
many different configurations, they can be adapted to
local contexts and work under very different circum-
stances, while still producing the expected results. This
flexibility makes vouchers highly suitable to apply in
tandem with other RBF approaches, such as cash transfer
programs and performance-based financing interventions.
Furthermore, as we have seen, voucher distribution sys-
tems are used to channel non-financial benefits such as
transport and food, as well as additional financial subsidies
(i.e. cash payments, insurance benefits) to voucher clients.
The above analysis shows a significant increase in vou-
cher programs from 2005 onwards (see Figure 3 above).
This is largely made up of a proliferation of small schemes,
either attached to social franchising networks where
vouchers enable franchised providers to use subsidies
(often from donors) to attract poorer clients, or small pilot
schemes, introduced with a view to future scaling-up.
Although they can provide useful learning, these pilot
schemes can lead to fragmentation and do not always
support the smooth progression towards universal health
coverage which national governments seek to follow. The
past decade has also witnessed the development of six lar-
ger voucher programs, not seen since the 1960s and 70s, at
a rate of one new scheme every two years since 2006.
We can only speculate about the reasons for this in-
crease, but from the review of 40 programs it is reasonable
to hypothesise that a number of factors may be at play,
including the capacity of vouchers to target the most vul-
nerable and contribute to their positive health seeking be-
haviour; and the flexibility of vouchers to work across a
wide range of contexts, employing different configurations
of organisations to oversee and implement the program,
and different types of providers, benefits and target popu-
lation groups. Disappointing progress towards achieving
the MDGs (particularly MDG 4 and 5), together with in-
creasing attention on achieving universal health coverage,
has also led to more detailed analysis of who is left out in
terms of access to critical public health services and, as we
have seen, vouchers do offer a solution to targeting under-
served groups. While donor financing for social franchis-
ing has been increasing, it brings with it an equity-related
objective to reach the poor – hence the continued rise in
the number of voucher schemes linked to franchises. And
finally, the number of research papers on vouchers has in-
creased significantly over the past five years [17] leading
not only to higher visibility, but also increased confidence
in the approach.
For those working in the design of voucher programs,
there is increasing realisation that vouchers constitute a
useful approach to enabling access, not only to SRH ser-
vices but to other critical public health services such as
chronic conditions and infectious diseases such as TB. It
is likely that we will see a wider basket of voucher services
over the next decade. As can be seen in Tanzania, as well
as introducing many of the key capacities for social health
insurance, vouchers are used to provide access to existing
insurance schemes, and in high income countries there
are voucher programs that provide access for specific
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http://www.equityhealthj.com/content/13/1/33
target groups, such as immigrant workers in the US, or
older people in Hong Kong, to a wider spectrum of ser-
vices. A continuum would seem to exist with simple
voucher schemes providing access to a single service for
a specific disadvantaged group at one end, and social
health insurance at the other. Voucher schemes which
provide access to a wider basket of services and where a
nominal fee is charged for the voucher at the distribu-
tion point (pre-payment) are closer to insurance pro-
grams on this continuum.
Criteria for successful voucher programs and their
limitations
However, not every health intervention lends itself well
to the voucher approach. Using the extensive review of
the literature and authors’ own experiences, the follow-
ing criteria were developed for successful voucher pro-
gram design:
1. Voucher services should relate to a common
condition in order to ensure sufficient demand
which in turn ensures sufficient client volume for
participating providers, and facilitates the
identification of, and voucher distribution to,
eligible people;
2. Services need to be clearly definable in order to
allow for manageable claims processing, i.e.
conditions for which the clinical need is largely
predictable, with clearly defined criteria for diagnosis
and disease severity, agreed protocols for
management, as well as tightly defined management
protocols that are common across groups of
consumers;
3. Services should have a start and an end to limit
payment to clear conditions, i.e. pregnancy and
delivery, or tuberculosis diagnosis and treatment.
With child care or even chronic conditions, this can
be done by defining the length of time during which
the treatment is covered by the voucher, and after
which the patient is appropriately referred to
the corresponding services or ceases to receive
the subsidy;
4. Acute cases cannot be addressed through this
approach because the patient needs time to learn of
and understand the scheme, receive and use the
voucher. Accidents or other sudden conditions, such
as gender based violence (GBV), are not ideally
suited to vouchers, as illustrated by the slow up-take
of the GBVR vouchers in Kenya. For these schemes
to work, the vouchers must be kept at the health
facility and knowledge must be widespread in the
surrounding communities that services are available
and provided for free. In such cases, vouchers act
predominantly as a reimbursement mechanism;
5. The treatment for the intervention should be offered
(or potentially offered) by a range of providers.
Special treatments that can only be offered in
referral hospitals do not suit this approach unless
the treatment is a referral from a voucher service
provided at lower level facilities (such as a
Caesarean-section or treatment of cervical cancer);
6. To justify the costs of voucher distribution and
claims processing, interventions should be priority
services as defined by the Ministry of Health, which
are currently under-consumed by a specific group,
and relevant to solve important public health
problems (e.g. high maternal mortality, unsafe
abortion, high fertility, high health system costs of
untreated diabetes and so on).
7. There are additional aspects of voucher programs’
performance that cannot be discussed in this review
as the data are simply not available. However, going
forward, voucher programs could make substantial
contributions by adapting standard performance
indicators. The five here, framed as questions, could
help to measure and compare the performance of
voucher interventions using routine program data:
� What proportion of clients are new users/
adapters in any given voucher service?
� How cost effective or efficient is any given
voucher service?
� What is the level of quality in any given voucher
service?
� How many DALYs averted or CYPs gained can
be attributed to any given voucher service (net
programmatic contribution)?
� What proportion of voucher clients are poor in
any given voucher service?
All services currently provided through the voucher
schemes identified in this review adhere to these seven
criteria set out above.
Conclusion
Vouchers are a promising and increasingly visible ap-
proach to target subsidies to individuals who, in the
absence of the subsidy, would likely not have sought
care. A large increase has been observed in the number
of voucher programs since 2005, and a corresponding
increase in the number of studies of voucher programs,
contributing to building the evidence base. Possible rea-
sons for this are related to specific strengths of voucher
schemes, such as the ability to incentivise changes in be-
haviour among both consumers and providers (a com-
bined demand- and supply-side effect), and the capacity
to target and channel resources to the most vulnerable.
Other more political factors, such as the increasing
Grainger et al. International Journal for Equity in Health 2014, 13:33 Page 16 of 25
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attention paid to achieving universal health coverage and
donor interest in reducing inequities in access to essen-
tial health services have also played a part.
Whereas the review identified many differences between
voucher schemes related to their structure and implementa-
tion arrangements, the commonalities, and in particular the
incentive structure whereby the client passes the subsidy or
incentive to the provider, seem to override many of these
differences. In all programs, a positive behavioural response
is observed with providers investing voucher revenue to im-
prove quality and attract more clients, and clients accessing
SRH services which they were not previously using.
The review found that all programs aim to increase
utilization of priority health services, particularly SRH
services, mostly among poor underserved and/or vulner-
able populations. The programs reviewed adhere to cri-
teria that make voucher services more functional, such
as services that are related to relatively common condi-
tions, are clearly definable, time-limited (with a begin-
ning and an end) and are sufficiently relevant within the
country’s health policy framework to justify the costs of
voucher distribution and claims processing. New vou-
cher programs are already providing access to a wider
basket of voucher services and it is likely that this trend
will continue over the next decade, with vouchers for
child health, chronic conditions and infectious diseases.
The review also noted that, while most voucher pro-
grams remain too small to adequately address national
level need among the poor, large programs are being de-
veloped at a rate of one program every two years since
2006, with further programs in the pipeline. The import-
ance of addressing the huge poor-rich inequalities in ac-
cess to basic services is well recognized as an important
component in the drive to achieve universal health
coverage; vouchers are increasingly acknowledged as a
promising targeting mechanism in this context. As the
movement for universal coverage develops [18], greater
consideration could be given to the relative strengths
and weaknesses of targeted social protection programs
and the role of vouchers in achieving larger equity gains
in the health sector, especially in contexts where a full
social health insurance model is not cost-effective.
aMost countries where a program was identified had a
Gross National Income (GNI) below US$ 1,400 in 2010
with the exception of Armenia (3,200 US$). The GNI of
China, Korea, Indonesia and Taiwan was also higher than
US$ 1,400 in 2010, but at the time of implementation this
was much lower. GNI per capita of low-income country in
2010 is less than 1,006 US$; lower-middle income country
1,006 US$-3,975 US$, upper middle income: $3,976 –
$12,275; high income, $12,276 or more (World Bank:
http://data.worldbank.org/indicator/NY.GNP.PCAP.CD).
Appendix
Complete list of published documents consulted for
the literature review, organised by country
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� Bellows N, Bellows B, Warren C: The use of
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� Meyer C, Bellows N, Campbell M, Potts M: The
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� Gorter AC and Bellows BW, Do competitive
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care to underserved and/or vulnerable population
groups? Experiences from Nicaragua, India and
Africa. April 24 2008, Invited Seminar, Department
of Social Medicine, University of Bristol.
� Sandiford P, Gorter A, Rojas Z, Salvetto M. A
guide to competitive vouchers in health. Private
Sector Advisory Unit, 2005, World Bank Group,
Washington, DC, 2005. ISBN: 0-8213-5855-3.
� Gorter AC, Sandiford P, Rojas Z, Salvetto M.
Competitive Voucher Schemes for Health.
Background Paper. 2003, ICAS together with
Private Sector Advisory Unit, World Bank Group,
Washington, DC.
� Gorter A. Evidence of effectiveness of competitive
voucher schemes on HIV prevention and care
for young people. Background paper ‘Global
consultation on the health services response to the
prevention and care of HIV/AIDS among young
people’ organised by WHO with UNFPA, UNAIDS,
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ARMENIA
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H, Petrosyan V, Truzyan N: Evaluation of the Child
Health State Certificate Program, 2011, Center for
Health Services Research and Development of the
American University of Armenia, Yerevan, Armenia.
� Truzyan N, Grigoryan R, Avetisyan T, Crape B,
Petrosyan V: Protecting the right of women to
affordable and quality health care in Armenia,
analysis of the obstetric care state certificate
http://data.worldbank.org/indicator/NY.GNP.PCAP.CD
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program, 2010, Center for Health Services Research
and Development of the American University of
Armenia, Yerevan, Armenia.
� Obstetric Care State Certificate Program: CHS
Newsletter Issue 5, Winter-Spring 2010, American
University of Armenia, Yerevan, Armenia.
� Avetisyan T: Equitable cost burden for women:
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program in Armenia, 2011, Presentation School of
Public Health, Boston University, Boston, USA.
BANGLADESH
� Hatt, L, Nguyen H, Sloan N, Miner S, Magvanjav O,
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Islam M, Wang H: Economic Evaluation of
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� Schmidt, JO, T Ensor, Hossain A, Khan S:
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� Ahmed S, Kahn MM: Is demand-side financing
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� Nguyen HTH, Hatt L, Islam M, Sloan NL,
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Encouraging Maternal Health Service Utiliza-
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� Rahman, M, Rob U, Tasnima K: Implementation
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� Koehlmoos T.L.P., A. Ashraf, et al.: Rapid assess-
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Bangladesh. Dhaka, International Centre for Diar-
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CAMBODIA
� Ir P, Horemans D, Souk N, van Damme W: Using
targeted vouchers and health equity funds to
improve access to skilled birth attendants for poor
women: a case study in three rural health districts
in Cambodia. BMC Pregnancy and Childbirth 2010,
10: 1–11.
� Ir P, and Wilkinson D: Social Health Protection
for the Poor and Vulnerable in Cambodia: the
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Protection Program Vouchers for Reproductive
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Health Management.
� Marie Stopes International Cambodia: A pilot
results-based approach to increasing access to
quality reproductive health services for peri-urban
and rural populations in Cambodia, 2011, Phnom
Penh, Cambodia.
� Gorter AC: Quick Assessment of Vouchers
implemented by MSIC in Cambodia Workshop
building OBA capacity MSIC staff: March 2011.
Project “Building Capacity in Local Authority and
Private Sector Sexual and Reproductive Healthcare
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� Reproductive Health Association of Cambodia:
Health Equity Fund with Reproductive Health
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� Sovannarith E, Keovathanak K: Review of Health
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� Hiwasa A. The Experiences and Perspectives on
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“The First Delay”, A thesis submitted to a partial
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Amsterdam, The Netherland, August 2010.
� Souk N, Horemans D, Ir P: Follow-up Evaluation of
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� Ir P, Horemans D, Souk N, van Damme W, Improving
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case study of Vouchers plus Health Equity
Funds in three health districts in Cambodia;
Studies in Health Services Organization & Policy,
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� IGES Institut GmbH: Linking Directly Targeted
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� Quarter 2 Report by EPOS Health Management,
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� Murakami H, Nagai M, Matsuoka S, Obara H:
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CHINA
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� Bloom G, Liu J, Qiao J, A Partnership for Health
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HONG KONG
� Yam CHK, Liu S, Huang OHY, Yeoh E, Griffiths
SM: Can vouchers make a difference to the use
of private primary care services by older people?
Experience from the healthcare reform programme
in Hong Kong. BMC Health Services Research
2011, 11:255.
� Department of Health, Health Care Voucher
Scheme for the Elderly, September 2, 2008,
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INDIA – AGRA (USAID)
� Mishra AK, Singh S, Sharma S, Sharma S, Singh S,
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& Child Health Services? Evidence from Rural Uttar
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� Das U, Ranjan R, Mishra A, Liberhan T, Kandwal
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� Arora R, Neogi S, Misra M: Innovative Ways to
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� Donaldson, D., H. Sethi, and S. Sharma: Vouchers to
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[abstract].
BCC: Behaviour change communication; BPL: Below poverty line;
CCT: Conditional cash transfer; DFID: UK Department for international
development; DSF: Demand side financing; FP: Family planning; GBV: Gender
based violence; GBVR: Gender based violence recovery; GoK: Government of
Kenya; GPOBA: Global partnership on output-based aid; HEF: Health equity
fund; KfW: German development bank; MDGs: Millennium development
goals; MIS: Management information system; MOH: Ministry of health;
MOMS: Ministry of medical services; MOPHS: Ministry of public health and
sanitation; MSI: Marie stopes international; NGO: Non-governmental
organisation; NHIF: National hospital insurance fund; OCSC: Armenian
obstetric care state certificate; PBC: Performance-based contracting;
PBF: Performance-based financing; PMTCT: Prevention of mother to child
transmission; PMU: Program management unit; PPP: Public private
partnership; PSI: Population services international; RBB: Results-based
budgeting; RBF: Results-based financing; RH OBA: Reproductive health
output-based Aid; RHVP: Reproductive health voucher program; SF: Social
franchise; SFO: Social franchising organisation; SHI: Social health insurance;
SMH: Safer motherhood; SRH: Sexual reproductive health; STI: Sexually
transmitted infection; TB: Tuberculosis; USAID: United States agency for
international development; VMA: Voucher management agency;
VP: Voucher program.
The authors declare that they have no competing interests.
CG participated in discussions on the research agenda, worked with AG on
the literature review, acquisition of data through networking, analysis and
interpretation of those data, and led the final drafting of the manuscript. AG
made substantial contributions to conception and design, led the acquisition
of data, analysis and interpretation of data, and made substantial contributions to
drafting the manuscript. BB conceptualized the initial research agenda, reviewed
the data collection templates, and made substantial contributions to drafting the
manuscript. JO was involved in literature review, interpretation, drafting,
organizing and overall revision of the manuscript. All authors read and approved
the final manuscript.
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1Options Consultancy Services Ltd., Senior Technical Specialist, Devon House,
58 St Katharine’s Way, London E1W 1LB, UK. 2Instituto CentroAmericano de
la Salud, Epidemiology, Managua, Nicaragua. 3Population Council, Ralph
Bunche Rd., PO Box 17643-00500, Nairobi, Kenya.
Received: 11 June 2013 Accepted: 19 March 2014
Published: 29 April 2014
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doi:10.1186/1475-9276-13-33
Cite this article as: Grainger et al.: Lessons from sexual and reproductive
health voucher program design and function: a comprehensive review.
International Journal for Equity in Health 2014 13:33.
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Abstract
Background
Methodology
Results
Conclusions
Introduction
Dramatic gaps in health
Result-based financing
Voucher schemes
Methods
Results
General program characteristics: objectives, financing, size and coverage
Management and governance
Provider autonomy
Voucher benefits and clients (demand side characteristics)
Providers (supply side characteristics)
Discussion
Criteria for successful voucher programs and their limitations
Conclusion
Endnotes
Appendix
Abbreviations
Competing interests
Authors’ contributions
Author details
References
