Vouchers for reproductive health (RH) are designed to stimulate demand in low-income markets for underutilized health services (e.g., family planning, antenatal and postnatal care, delivery), particularly in markets characterized by high inequalities. But how can successful voucher programs continue to grow to cover those who still aren’t receiving care? At a technical advisory meeting in Cambodia in May, I had a chance to hear about five RH voucher programs that target services to the poor.
RH Vouchers in Cambodia
The German Development Bank (KfW) is currently funding an RH voucher program in Cambodia that provides women with vouchers for safe motherhood, family planning, and safe abortion services. At a public clinic near Kampong Thom, Cambodia, where Action for Health is managing the roll-out of this program, the medical staff there has seen an increase in the number of women seeking care for reproductive health services. At a Marie Stopes International (MSI) clinic nearby, patient volumes have nearly doubled; and 3-times as many women are now seeking services, such as those for safe abortions. As a reference point, the full cost of a delivery at a facility can cost well under $100 – almost 3 months’ salary for those living under $1.25/day.
RH vouchers from the KfW-funded program in Cambodia
The RH voucher program in Cambodia is one of five RH voucher programs that are currently being evaluated for their impact by the Population Council. The other countries are Bangladesh, Kenya, Uganda, and Tanzania. In May, the Council convened these programs together in Cambodia to update each other on their progress and to share findings from Council evaluations. Preliminary results in many of these countries suggest that after RH vouchers were introduced, utilization of RH health services increased, service delivery to the poor improved, and patients felt empowered and knowledgeable about specific health issues. RH vouchers can also provide resource-strapped healthcare providers with additional revenue from poor patients, who otherwise would have been priced out of the market. At the MSI clinic we visited, staff estimated that 90% of the clinic’s current revenues came from the RH vouchers.
Growing what works
Given the promise of RH vouchers, the Population Council chose to engage its partners in a meaningful discussion around how these programs could achieve scale. Should programs offer more services where they currently operate? Should they expand to new regions? Can programs expand by leveraging the private sector and link with providers with established delivery networks? (My colleague Gina Lagomarsino has already written about the potential synergy she sees between vouchers and social franchises.) If programs choose to grow through the public sector, how can they do so in tandem with existing government financing or universal health coverage schemes? These are a few of the questions the meeting attendees discussed.
Strategies for scaling will likely require both finding greater efficiency in expanded program operations and demonstrating to national stakeholders and development partners that these programs can accelerate uptake of critical services among the poor, who in the absence of the targeted subsidies, would likely not have sought care.
• In Tanzania, the voucher program issues a voucher for insurance and officials see the voucher as an important way to introduce poor households to the value of insurance products.
• In Uganda, the MOH and development partners view vouchers as a cost-efficient way to subsidize access to RH services for the poor across the country.
• Both Kenya and Cambodia are keen to incorporate vouchers into the broader healthcare financing fabric, and Bangladesh views the initiative as an effective way to support mostly public facilities through demand-side incentives.
It was clear from the meeting that each program’s scale-up strategy will vary, but that programs gained when able to get together and discuss issues, such as beneficiary identification, claims management, and quality assurance.
The Center for Health Market Innovations currently profiles 35 programs that are using vouchers to finance healthcare. Of these programs 19 are providing family planning and reproductive health. Click here to learn more about these programs.
Written in collaboration with Ben Bellows, Population Council