1. RH Vouchers and Health
Systems
Ben Bellows, PhD
The Role of Vouchers in Serving Disadvantaged
Populations and Improving Quality of Care
November 6th 2014
World Bank, Washington, DC

2. Overview
• Necessary conditions for successful RH voucher programs?
• Design characteristics of voucher programs?
• What is the coverage for RH voucher programs?
• How much would it cost to scale up RH voucher programs?
• How can vouchers fit into national objectives and international
health goals?

4. Consider pre-conditions for scaled voucher programs
POPULATION
PROVIDERS
HEALTH
SYSTEM &
GOVERNANCE

5. Population characteristics
• Gap in high quality RH service consumption
• Inequity in distribution of RH services & ability
to pay
• Ability to identify target population
• Beneficiary’s agency on FP/RH issues (e.g.
future-oriented, ability to make decisions,
male support)

6. Health care provider characteristics
• Facilities must meet standards to be contracted
– Tanzania (equipment to public facilities)
– Cambodia (MOH QoC standards: pass, no pass)
– Uganda (A, B, C)
• Routine quality improvement: QoC decreases are of concern
• Providers located in areas accessible to target population
(transportation issues & marginal quality at remote facilities)
• Composition of providers
– public/private
– dual practice
• Capacity to treat and efficiency with increased volume of patients

7. Use of voucher reimbursements in
Kenya 2009-2011
Construction Maternity wing; others Renovation and Repairs Maternity wing; other; sanitary (water, toilets etc)
Human resources employment of doctors, nurses, support staff, salaries & wages, staff incentives, training
Medical procurement Beds, nets, medical equipment, drugs, medical supplies Non-medical procurement Vehicle,
land, furniture, water or power equipment, appliances, non-medical supplies Other recurrent costs Patient
nutrition/meals, incentives to mothers, repair of medical equipment, service hire

8. Facility efficiency in provision of delivery
services: Kenya
0%
20%
40%
60%
80%
100%
Kyambeke HC
Mbitini HC
Miambane HC
Yatta HC
Lari HC
Ngewa HC
Nyanza PGH
Kitui DH
Kiambu DH
Tigoni SDH
Kauwi SDH
Mutito SDH
Chulaimbo DH
Kisumu East DH
Limuru NH
St Teresa NH
St Monica Hospital
Nightingale Hospital
Port Florence Hospital
St. Elizabeth Chiga…
Health Center Hospitals Hospitals Dispensary
Public Facilities Private Facilities
Efficiency Scores
Facilities

9. Government and health system
characteristics
• Voucher management agency
– autonomy
– capacity to quickly & consistently disburse on time
– measure quality
– “trouble shoot” or innovate
– Avoid over-centralized planning and adding burdens to
existing agency without sufficient support
• Vouchers ought not to compete with existing
programs with similar goals (e.g. Cambodia and health
equity funds)

10. Coverage by RH voucher programs
Country
(DHS &
program
years)
Total
births
% facility-based
births
(DHS)
Births at
poorest
40% HH
% facility
births for
poorest
40%
(DHS)
Yearly
vouchers
issued
Yearly
voucher
deliveries
Voucher
deliveries
among all
deliveries
(yearly)
Voucher
deliveries
among
bottom
40%
Cambodia
(2010,
2013) 367,000 53.8% 146,800 39.2% 9,248 5,814 1.6% 4.0%
Banglades
3,401,00
1,360,40
h (2011,
2013)
0 29.0%
0 13.7% 156,937 129,616 3.8% 9.5%
Kenya
(2009,
2013)
1,596,73
3 43.0% 638,693 24.2% 53,404 45,354 2.8% 7.1%
Tanzania
(2010,
2013)*
1,813,38
5 50.0% 725,354 34.7% 45,751 15,160 0.8% 2.1%
Uganda
(2011)
1,502,00
0 57.4% 600,800 45.6% 58,397 31,012 2.1% 5.2%

11. Scaling beyond pilot programs for
effective social protection: Kenya
2015
Deliveries among 40% poorest 410,443
Service reimbursement $46,450,233
Program management $6,406,929
Total cost $52,857,161
Cost per maternal voucher $128.78
• 2011 MOH budget US$465 million (41 billion KES)

12. International health goals: UHC
1. Access: expand population covered
2. Scope: improve quality /quantity of health
services offered
3. Financial protection: improve size of
subsidies (or regulation of informal charges)
universal can vouchers really be?
growing evidence for vouchers’
impressive impact in terms of equity,
protection and quality of care, they
for now a specific tool to enable
underserved groups to access priority
However the WHO’s ‘cube’ frames
towards UHC in terms of the share
people, services and costs covered, with
on growing these three dimensions
as possiblexi. Given this
understanding of UHC, how important can

13. Conclusions
• Vouchers can work, but consider conditions and have
an appropriate design
• Vouchers can be a responsive, scalable strategy to
accelerate progress on global health priorities
• Incomplete evidence:
– Do vouchers prime users and providers for a better
understanding of insurance concepts?
– How to standardize and validate equity measurement in
voucher program operations (e.g. DHS quintiles)?
– What “nudge” strategies can convert voucher holders to
service users (e.g. lotteries, expiry dates)?

14. Thank you