A taxonomy and systematic review of maternal voucher programs: Recommendations for policy, practice and research

Ben Bellows1, Claudia Morrissey2, Elizabeth Higgs2, John Townsend1, Matta Nahed2, Karen Cavanaugh2, Jeff Sine3, Corinne Grainger4, Anna Gorter5

1Population Council, 2USAID, 3RTI, 4Options Ltd., 5consultant

Growth paradox: Widening inequality within countries even as economies converge

"Countries across Africa [and Asia] are becoming richer but whole sections of society are being left behind.... The current pattern of trickle-down growth is leaving too many people in poverty, too many children hungry and too many young people without jobs."

- Africa Progress Panel, May 2012

Inequitable MNCH services*

• Of 12 MNH interventions in a review of public data across 54 countries, family planning was the third most inequitable

*Barros, A. J. D., Ronsmans, C., et al. (2012). “Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries”. Lancet, 379(9822), 1225-33.

Targeting counterfactual non-users

• Vouchers are intended for poor beneficiaries who, in most cases, would not have used the service if the voucher were not available

Voucher functions (management)• Decide to government-run, contract-out, or franchise• Conduct provider administrative & clinical training (i.e. CMEs)• Design & maintain claims processing & fraud control• Monitor costs, utilization, quality• Offer financial credit to facilities

Facility• Accredited? • Clinical quality?• Competition?• Reimbursement rates?

Client • Poverty status & need? • Free or paid voucher?• Which services

offered?

Voucher program design & functions

Program objectives, funding sources, timeframe, governance structures

Inputs Implementation

Objectives

Structures: management &

governance

Providers engagement

Implementation arrangements

Outputs & outcomes

Utilization & equitable access

Costs

Quality of care

Knowledge

Health status

Scale

Organizing what is known about vouchers

Methods: Systematic review

• Began with the same key terms and search strategy as two previous published reviews of voucher evaluations (see Acknowledgments)

• Searched bibliographies to identify other studies and programs

• Interviewed key informants to fill gaps

= 28 safe motherhood voucher programs

Results: Objectives for voucher programs

Improve social protection coverage among the poor

Vouchers are intended to influence the demand for and supply of health services

Trigger competition to improve service quality and uptake

Generate greater efficiency for facilities seeing higher patient volumes

Build capacity, norms for social health insurance

Regulate private sector providers

Results: Active maternal voucher programs by year

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

0

2

4

6

8

10

12

14

16

18

smallmedium large

Year

Num

ber

of

Acti

ve P

rogra

ms

28 maternal voucher programs with additional services

SMH only SMH & FP & STIs

SMH & FP SMH & STIs0

2

4

6

8

10

12

14

16

18 17

5 5

1

Funding Organizations

Funder type Number Region

Donors 14 South Asia, East Asia, Africa

Government & donors 8 South Asia, Africa

Government 4 South Asia, West Asia

Social franchises 2 South Asia, Africa

TOTAL 28

Provider types in 28 maternal voucher programs

private mostly private

mixed mostly public

public0

2

4

6

8

10

12

1413

4

5

1

5

Evaluations aren’t the whole picture

programs under study programs without studies0

2

4

6

8

10

12

14

16

13

15

Evaluation outcomes (1 of 2)Outcome type

Number of studies

Direction of effect & gaps in research

Targeting 3 studies Positive effects: inequalities were reduced.

Missing: nationally standard measures.

Costing 2 studies Positive effects: OOP spending reduced.

Missing: cost-effectiveness, administrative-to-service delivery ratio

Knowledge 2 studies Positive effects: increased knowledge of important health conditions.

Missing: measures of community norms and partner knowledge.

Evaluation outcomes (2 of 2)Outcome type

Number of studies

Direction of effect & gaps in research

Utilization 13 studies Positive effects: increased use of ANC, facility deliveries.

Missing: Postnatal care.

Quality 4 studies Positive effects: improved customer care, infrastructure upgrades. Missing: clinical care scores.

Health 4 studies Positive effects: modeled decreases in maternal & neonatal mortality

Missing: sensitivity analysis, DALYs averted

Two challenges: “metrics & scale” … “Or how to know when you’ve had a big, big impact”

• Largest maternal voucher programs operate at $1m-$3m per year

• Deliver 3-5% of all births in Cambodia, Kenya, Bangladesh and Uganda

• Greater efficiency is required if programs are to scale from 3% to 30% of general population

• Needed: routine performance metrics, ideally drawn from operational data (efficiency, quality, equity, DALYs averted)

Acknowledgments Members of the USAID Evidence Review Team 3:

Chair: Claudia Morrissey, USAID

Co‐Chair: Laurel Hatt, Abt Associates

Amy Tsui, Johns Hopkins University Bloomberg School of Public Health

Ana Langer, Harvard School of Public Health

Ben Bellows, Population Council

Bert Peterson, University of North Carolina at Chapel Hill Gillings School of Global Public Health

Craig Lissner, World Health Organization

Hendree Jones, RTI International

Isabella Danel, Centers for Disease Control

Jeff Sine, RTI International

Jessica Celentano, Harvard School of Public Health

John Townsend, Population Council

Karen Cavanaugh, U.S. Agency for International Development

Karen Fogg, U.S. Agency for International Development

Korde, Sonali, U.S. Agency for International Development

Marion Koso‐Thomas, National Institute of Child Health and Human Development

Nahed Matta, U.S. Agency for International Development

Ratha Loganathan, U.S. Agency for International Development

Robert Balster, U.S. Agency for International Development

Saifuddin Ahmed, Johns Hopkins University Bloomberg School of Public Health

Supriya Madhavan, Johns Hopkins University Bloomberg School of Public Health

Ubaidur Rob, Population Council, Bangladesh

Meyer, C., Bellows, N., Campbell, M., & Potts, M. (2011). The impact of vouchers on the use and quality of health goods and services in developing countries: A systematic review (pp. 1–86). London. Retrieved from http://eppi.ioe.ac.uk

Bellows, N. M., Bellows, B. W., & Warren, C. (2011). The use of vouchers for reproductive health services in developing countries: systematic review. Tropical Medicine & International Health, 16(1), 84–96. doi:10.1111/j.1365-3156.2010.02667.x