October, 2016 - SUPPORT Summary of a systematic review | print this article |

What is the impact of vouchers on the use and quality of health goods and services?

Voucher programmes are a strategy to distribute health aid to people in disadvantaged conditions. They are used especially in low and middle income countries to address health inequalities in the use and access to health goods and services, and to improve efficiency in their delivery. The end goal of voucher programmes is to improve the health of the population.

Key messages

 

  • Vouchers may improve the utilization of reproductive health services, targeting specific populations, quality of care, and health outcomes.
  • Vouchers may improve the utilisation of insecticide treated bed nets and targeting specific populations.
  • The effect of vouchers for insecticide treated bed nets on quality of care and health outcomes is uncertain.
  • The cost effectiveness of voucher programmes is uncertain for both reproductive health services and insecticide treated bed nets.
  • All the included studies were conducted in low and middle income countries.

 

Background

One rationale for subsidising healthcare is the inequitable distribution of wealth and healthcare resources. Low income individuals lack adequate finance and knowledge to access and use the healthcare they need, particularly in the private sector. Voucher programmes are a form of outputbased aid, where aid funding is used to stimulate demand for health goods and services. They contrast with traditional supply side strategies, which often focus on providing the inputs for health services such as construction of facilities or provision of supplies.



About the systematic review underlying this summary

Review objectives:To assess the effects of vouchers on health goods and services utilisation, quality, efficiency in delivery, targeting and health outcomes in low and middle income countries.
Type of What the review authors searched for What the review authors found
Study designs & interventions Studies of voucher programmes for health goods and services in low and middle income countries with a comparison such as before and after programme implementation, control groups, control programmes or comparison with accepted benchmarks of success
24 studies of 16 health voucher programmes; including 19 observational studies (pre/post design, cross sectional intervention/comparison or before after with controls design), 1 case control study, 2 economic modelling studies, 1 clinical record review, and 1 evaluation using a simulated patient
Participants Populations that would potentially use vouchers for health goods and services in low and middle income countries
Reproductive health programmes for pregnant women and adolescents that provided maternity services, family planning (FP) and treatment for sexually transmitted infections (STI) (9 studies); Insecticide treated bed net (ITN) distribution programmes for households, pregnant women and infants (6 studies); General health services payment programme (1 study)
Settings All studies conducted in low and middle income countries
Bangladesh (3 maternity studies), Cambodia (1 maternity study), India (2 maternity studies), Mozambique (1 ITN study), Nicaragua (5 reproductive health and 2 STI studies), Niger (1 ITN study), Senegal (1 ITN study), Taiwan (1 FP study), Tanzania (4 ITN studies), Uganda (1 STI study), Zambia (1 ITN and 1 health services)
Outcomes Targeting specific populations, utilisation and quality of health goods/services, efficiency in delivery of health services and health outcomes
Studies provided data on targeting specific groups (6 studies), utilisation (16 studies), quality of goods/services (6 studies), efficiency in delivery (1 study), and health impact (6 studies).
Date of most recent search:October 2010
Limitations: This review has important limitations due to uncertainty in risk of bias assessments and how the results were synthesised.

Brody CM, Bellows N, Campbell M, Potts M. The Impact of vouchers on the use and quality of health care in developing countries: A systematic review. Global Public Health 2013; 8:(4)363-88.

Summary of findings

The review found 24 studies of 16 voucher programmes for health goods and services. Of the 16 programmes, eight were located in Africa, five were in Asia and three were in Latin America (all about one programme in Nicaragua).

Nine programmes included some aspect of reproductive health such as maternity services, family planning, treatment for sexually transmitted infections and cervical cancer screening. Six programmes were for insecticide treated bed net distribution.

 1) Reproductive health services

 15 studies assessed the effects of vouchers on different aspects of reproductive health services: maternity services, treatment for sexually transmitted infections, cervical cancer screening and family planning.

  • Vouchers may improve the utilization of reproductive health services, targeting specific populations, quality of care, and health outcomes. The certainty of this evidence is low.
  • The cost effectiveness of vouchers for reproductive health services is uncertain. The certainty of this evidence is very low.

Effects of voucher programmes for reproductive health services

People: Women and adolescents.
Settings
:  Low and middle income countries.
Intervention
Vouchers for health goods and services.
Comparison
Women and adolescents receiving reproductive health services with and without vouchers.
Outcomes Impact No of Participants
(studies)
Quality of the evidence
(GRADE)
Utilisation

There was a positive effect for 10 out of 15 outcomes, including: % of deliveries attended by skilled providers, % of facility based deliveries, % attending antenatal care more than once, % of women using ultrasound services, % of women receiving cervical cancer screening, and % of adolescents using reproductive health services.

 

No evidence of an effect was found on the % of women receiving postnatal care, the % of adolescents using modern family planning methods, the % using condoms in last sex act, or on the % of people seeking treatment for sexually transmitted infections (STIs).

 

8 studies


Low

 


Quality

A positive effect was found on the reliability of detection of papilloma virus through cervical cancer screening, patient satisfaction with the programme, % facility deliveries as caesarean, % services delivered during antenatal care (ANC), % providers performing well on quality indicators at ANC visits, and mean score of doctors’ knowledge of contraceptive use and STI prevention and treatment.

An effect was not found on the % of appropriate family planning treatment, appropriate STI/HIV prevention, appropriate organisation of the clinic, or on doctors’ attitudes towards sexual and reproductive health accessibility and contraceptive use.

6 studies


Low

 


Targeting

One study showed a positive effect of vouchers in the % of women with a “below poverty line” card using maternity services (16.7% of non beneficiary women vs. 32.4%).

A study found a positive effect in the % of high risk women receiving cervical cancer screening (3.7%) compared to standard benchmarks (0.2%-1.5%).

2 studies


Low

 

Health Impact

One study showed a positive effect in the % of women not experiencing life threatening complications during pregnancy (an increase from 27% to 75%), delivery (41% to 75%), and postpartum (44% to 70%). Another study showed no effect on the % of complications during postnatal period.

There was no evidence of an effect on the prevalence of syphilis (3% to 3%) or on the self reported STI symptoms (42% to 40%) (1 study). There was a positive linear relationship in prevalence of STIs with time lag between voucher distributions as explanatory variable.

There was evidence of a positive effect in reduction of live births per 1,000 voucher acceptors of intra uterine devices (80% among cases compared to 48% among matched controls, 1 study).

5 studies


Low

 

Cost effectiveness

Positive reduction of costs per STI case cured (estimated cost of $118 STI effectively cured vs. $200 in the absence of the programme).

1 study


Very Low

 

GRADE: GRADE Working Group grades of evidence (see above and last page).

 

2) Insecticide treated bed net

 Nine studies assessed the effects of voucher programmes on the possession and utilization of insecticide treated bed nets, and impacts on the prevalence of malaria and anaemia.

 

  • Vouchers may lead to an increase in insecticide treated bed net utilization and may improve targeting of specific (disadvantaged) populations. The certainty of this evidence is low.
  • The effect of vouchers on the health outcomes (prevalence of malaria, anaemia) is uncertain. The certainty of this evidence is very low.
  • No studies were found that evaluated the effect of vouchers on the quality of care or the cost effectiveness of vouchers for insecticide treated bed nets.
 

Effects of insecticide treated bed net voucher programmes.

People: Households, pregnant women and infants.
Settings
:  Low and middle income countries.
Intervention
: Providing vouchers for the purchase of insecticide treated bed nets.
Comparison
: Household ownership of insecticide treated bed nets before and after a voucher programme.
Outcomes Impact No of Participants
(studies)
Quality of the evidence
(GRADE)
Utilisation
All of 11 reported outcomes showed a positive effect on the % of households owning and using an insecticide treated bed net (ITN) or any type of bed net, knowledge of voucher scheme as a predictor of net ownership, ITN ever treated, and ITN effectively treated.

6 studies

 

Low

 


Targeting

Positive effects were found on the % of insecticide treated nets purchased with a voucher in infants under one (increment from 7% to 50%); in children under five (3.5% to 33.5%) and in pregnant women 6.3% to 23.6%) (1 study). Likewise, positive effects were found among infants for ITNs purchased with a voucher (1 study). There was evidence of a positive effect on equity ratios of ITN ownership between high and low quintiles (1 study).

There was evidence of a negative effect of the impact of vouchers targeting poor pregnant women. 60% of the least poor pregnant women received and redeemed vouchers compared to 39% of the poorest. No evidence of an effect was found when targeting infants across socioeconomic levels (1 study).

4 studies

 

Low

 


Health Impact

No evidence of an effect was found on the prevalence of malaria, on mean haemoglobin levels, or on the prevalence of anaemia in children under five years and pregnant women (1 study).

1 study

 

Very Low

 

p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page)

 

 

 

 

 

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
All of the studies were from low and middle income countries.
In several low income countries, the level of education and access to information is precarious for poor and rural people. In this context, purchasing power does not mean on its own that the most vulnerable people would have access to more and better health goods and services.
EQUITY

Voucher programmes may improve targeting of disadvantaged populations.

 

  • In the few studies that evaluated the effect of voucher programmes on equitable access and utilization of health goods and services, negative effects or no evidence of an effect was found.

 


Voucher programmes may reduce inequitable access by targeting disadvantaged populations, but it is uncertain whether vouchers effectively increase the relative utilization by the poorest or most vulnerable people in comparison with the less poor or vulnerable people.
ECONOMIC CONSIDERATIONS

This review analyzed voucher programmes delivered by public and private for profit and not for profit providers, but it did not evaluate the performance and outcomes of private versus public providers.

 

  • Voucher programmes aim to use market mechanisms for the delivery of health services in order to stimulate demand for health services and goods, reduce costs, and improve quality and health.

 


Comparisons of investments in the private for profit sector to improve access and quality of care must be made with investments in the public sector. The ability of these investments to promote the quality of public services should be analyzed.

 

  • Further studies of the cost effectiveness of voucher programmes compared to other supply side strategies are needed.

 


MONITORING & EVALUATION
The certainty of the evidence is low or very low.

The successful implementation of voucher programmes might depend on local factors such as the organization and coordination of healthcare providers, health promotion strategies, and the ability to generate timely information in an accessible language to the population about their rights and health duties.

 

  • Effects on quality of care and costs might depend on the ability of the targeted populations and their access to necessary information to choose the provider that best meets their needs and preferences, in order to promote a level of competition among providers that could lower prices and increase quality.
  • Monitoring and evaluation is needed to ensure that voucher programmes adequately address the health needs of targeted populations and improve their health outcomes.

 


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods

 

Additional information

Related literature

Bellows N, Bellows B, Warren C. The use of voucher for reproductive health services in developing countries: systematic review. Tropical Medicine and International Health 2011; 16:(1)84-96.

 

Bhatia MR, Gorter AC. Improving access to reproductive and child health services in developing countries: are competitive voucher schemes an option? Journal of International Development 2007; 19:975.

 

Ensor T. Consumerled demand side financing in health and education and its relevance for low and middle income countries. International Journal of Health Planning and Management 2004; 19:267-85.

 

Gorter AC, Sandiford P, Rojas Z,Salvetto M. Competitive voucher schemes for health. Background paper. Washington, DC: ICAS/Private Sector Advisory Unit of the World Bank Group, 2003.

 

Grabowsky M, Nobiya T, Selanikio J. Sustained high coverage of insecticide treated bed nets through combined catch up and keep up strategies. Tropical medicine and international health 2007; 12:(7)815-22.

 

Murray SF, Hunter B, Bisht R, Ensor T, Bick D. Demand side financing measures to increase maternal health service utilisation and improve health outcomes: a systematic review of evidence from low and middle income countries. JBI Library of Systematic Reviews, 2012; 10(58):4165–567.

 

Sandiford P, Gorter A, Rojas Z, Salvetto M. A guide to competitive vouchers in health. Washington, DC: Private Sector Advisory Group, The World Bank, 2005.

 

This summary was prepared by

 Lucy Kuhn Barrientos, National Commission of Health Technology Assessment (HTA), Division of Health Planning, Undersecretary of Public Health, Ministry of Health, Chile.

 

 Conflict of interest

 None declared. For details, see: www.supportsummaries.org/coi

Acknowledgements

 This summary has been peer reviewed by: Ben Bellows and Carinne Brody.

 

 This review should be cited as

 Brody CM, Bellows N, Campbell M, Potts M. The Impact of vouchers on the use and quality of health care in developing countries: A systematic review. Global Public Health 2013; 8:(4)363-88.

 

 The summary should be cited as

 Kuhn Barrientos L. What is the impact of vouchers on the use and quality of health goods and services? A SUPPORT Summary of a systematic review. October 2016. www.supportsummaries.org

 

Keywords

 evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care, vouchers, aid resources, targeting, utilisation, efficiency, quality, health impact.

 

 

 

 

 

 

 



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