Competitive voucher schemes to increase access
to and quality of sexual and reproductive health
care for marginalized and/or vulnerable
populations
Anna Gorter
Julienne McKay
Instituto CentroAmericano de la Salud – ICAS
Reproductive health in Latin America: costs, outcomes and policies
London School of Economics and Political Sciences – Sept 20, 2007
Outline of presentation
What are competitive voucher schemes
Strengths of competitive vouchers in
developing countries
Comparison of vouchers with:

franchising programmes
Conclusion, can vouchers be used to
increase access to quality services for
marginalized and vulnerable populations
Why develop competitive
voucher schemes?
Market failure to serve certain poor,
marginalised and / or vulnerable
populations,
even if services are associated with
positive externalities, e.g. HIV/AIDS
services for sex workers or family
planning for young people
Search for alternative approaches –
engagement of private providers through
competitive vouchers
Competitive voucher schemes in
Nicaragua
1995 - 1998 voucher trial with sex workers
in Managua successful
Development of more schemes in
Nicaragua



Clients of sex workers, drug addicts, gay
men, young glue-sniffers, mobile populations
Adolescents, YP, especially poor “high-risk”
Older, poor, rural women at risk for cervical
cancer
SUBSIDIES
Eg. Tax revenue or donation
PAYMENT ORGANIZATION
PROVIDER ORGANIZATION
Eg. MoH,
Social Security, other.
Eg.
RIGHT TO
SUBSIDY
INPUTS
Eg. Salaries,
Drugs,
etc
Eg. Vouchers,
capitation
payment, fee
subsidies
Payments
USERS
PROVIDERS
Co-payments
Voucher Agency
Free or
subsidized
services
USERS
SUPPLY SIDE FINANCING
Invoice for
Subsidies on
Goods and /or
services
Redemption
of the right
for subsidy
PROVIDERS
DEMAND SIDE FINANCING
Competitive vouchers in other
sectors
Education (US, Europe, LA, Netherlands)
Employment (Argentina, US, Netherlands)
Training (LA, Kenya, Zimbabwe, USA)
Elderly care (Spain)
Housing (USA)
Pension (Bolivia)
Welfare (UK, USA)
Competitive voucher scheme
in health
Voucher
agency
$
Donor/
Government
Voucher
M&E reports
Training plus
performance
monitoring
Voucher
$
Service
Providers
(private, NGO and
public sector)
Voucher
recipients
Voucher
Some examples of vouchers
Strengths of competitive
vouchers
Targeting of population sub-groups
Encourage use of specific services
Can increase operating efficiency
Can improve service standards / quality
Payment for services actually provided

Possible to pay only incremental cost
Facilitates monitoring and evaluation
Targeting
Of identifiable groups ‘at risk’ / in need:
Marginalised groups

drug-addicts, sex workers, streetkids
Groups who fear stigmatization

MSM, or people with TB, Leprosy, AIDS
Vulnerable groups, e.g. because of age,
gender, behaviour or poverty



Adolescents, young people
Clients of sex workers
Poor pregnant women
Encourage use (incl. of services
with positive externalities)
When demand is limited by barriers to
access (cost, lack of knowledge, stigma..)
Vouchers inform about services and guide
users to where services can be obtained
Remove cost barriers (incl. eg transport costs)
Power of choice increases client satisfaction


Encourages use and positive experience leads to
repeat use
‘Worth of mouth’ recommendation to others
Nicaraguan schemes target those most
at risk or underserved & encourage use
STI-HIV-AIDS prevention & treatment


sex workers and their clients
men who have sex with men and other
populations which are difficult to reach
Sexual & Reproductive Health care

poor adolescents and young people
Cervical Cancer screening and treatment

older women in rural and remote areas
Other schemes target and encourage
use of safe motherhood services
Providing safe motherhood services through
vouchers to reduce maternal mortality (MDG5):
Indonesia: services delivered by private
midwifes to poor rural women
Kenya: services delivered by public, private &
mission providers to poor women
India / Gujarat: private gynaecologists provide
services to poor women from remote areas
India / Uttar Pradesh, private nursing homes
provide maternal care to poor women
Vouchers can increase
efficiency & service standards
Increased utilization of private sector
resources
Reduced input costs
Competition between participating
providers (private, NGO/mission, public) :



Reduced price
Increased service quality
Increased clients satisfaction
When do vouchers increase
efficiency / standards most?
Providers with excess capacity, increased
utilization gives economies of scale
Strong competition between providers (more
than one provider available)
Where contracts specify ‘best practice’ service
package /‘social’ protocols & staff required to
undergo training
only cost-effective services are provided
medical supplies are procured centrally
vouchers are distributed by third parties
Potential drawbacks of
vouchers
High start-up costs
Set-up is complex, needs highly trained staff at
the start, ‘devil in the detail’
Not feasible: cost of services is variable or
unpredictable; need for services difficult to
verify
May be susceptible to abuse (black market,
collusion between providers and distributors..)
Program development takes time
Once established easy to run and to scaleup, and costs go down
Vouchers facilitate
monitoring and evaluation
Mechanics of a scheme incorporate:
Regular monitoring of provider performance
against contract specifications



Interviews with redeemers, ‘mystery patients’
Medical record review
Tracking redemption rates / follow-up consultations
Providers report to voucher agency
Voucher agency reports to donor/Government
Program impact assessed by tracking voucher
use and linking changes to health outcomes
Impact of treatment rounds on STI prevalence in sex
workers voucher scheme in Nicaragua (long periods
between treatment rounds – high bounce back of STIs)
Measured STI Prevalence
35%
30%
25%
20%
15%
10%
5%
0%
0
1
2
3
4
5
6
7
8
9
Round
10 11
12 13 14 15 16 17 18 19 20 21
McKay et al, AJPH 2006;96:7-9
Cost-effectiveness study of sex
worker STI program
Annual cost voucher program is US$62,495
Estimated US$17,112 for regular STI care
provision in the absence of the scheme
In study year:


Vouchers: 528 STI cases cured of 1,500 patients
Regular care: 85 STI cases cured of about 1,400 patients
Costs per STI cured:


In case regular STI care: US$200 per STI
In case of voucher program US$118 per STI (while many
more STIs were treated, preventing further transmission
and reducing HIV transmission risk)
Borghi et al, Health Policy & Planning, 2005
Social franchising and voucher schemes:
comparing pilot programs outcomes in Nicaragua
Social franchising:
SRH clinics established
within youth organisations
1998-2000
18,000 adolescents reached
with IEC
3,000 used clinical services

but not all were adolescents
and not all for SRH care
Significant impact on
knowledge and attitudes
Cost effectiveness – likely to
be relatively low
Voucher scheme: vouchers
distributed to adolescents,
redeemable in contracted
clinics, 2000-2001
28,711 adolescents received
vouchers
4,012 redeemed voucher
Significant impact on knowledge
and use of contraceptives and
SRH services
Reached previously un-serviced
group

sexually active girls who had
never been pregnant
Cost effectiveness – possible
Lessons learnt
Social franchising
Franchisee organizations need
sufficient resources +
familiarity with health care
Provider personality and highquality provider interactions
more important to adolescents
than technical quality
Need to be able to specifically
target adolescents in
marketing
SRH care services need to be
located away from youth
organisations
Voucher scheme
Can increase satisfaction with
service quality

with female adolescents more
satisfied with female doctors
Can increase doctors’
knowledge and appreciation of
adolescent issues
Difficult to judge sustainability
of changes. Post intervention
study showed:


some improved practices
continued (shared decision
making; increased education
on condom use)
others had disappeared
(doctors initiating follow-up
consultations; providing
information on possible side
effects from contraceptives)
Comparative strengths
Targeting of population subgroups
Encourage use of specific
services
Can increase operating
efficiency
 Voucher scheme
Can improve service
standards
 Voucher scheme / social
Payment for services actually
provided
 Possible to pay only
incremental cost
Ease and speed of
establishment
Facilitates monitoring and
evaluation
 Voucher scheme / social
 Voucher scheme
 Voucher scheme / social
franchising
franchising
franchising
 Voucher scheme
 Voucher scheme
 Voucher scheme
Increasing efficiency & standards
Comparison of vouchers with
franchise and insurance
10
Franchise
- bulk purchasing lowers costs
- services standards set and
rigorously monitored
- limited incentive to target
populations or services
- incentive to over-service
8
6
Voucher program:
4
Subsidised health insurance
not 10-10 because of
- high set-up costs
- need to limit leakage
- covers only formal economy
- no brake on over-servicing
- unlimited financial liability of funding agency
2
0
0
2
4
6
Targeting & encouraging use
8
10
Increasing efficiency & standards
Combining vouchers with a
franchise
10
Voucher program/franchise
Franchise
8
6
Franchise/subsidised
community based
health insurance
4
Voucher program
Subsidised community
based health insurance
Subsidised health
insurance
2
0
0
2
4
6
Targeting & encouraging use
8
10
Conclusion
Vouchers are complex to set up but are highly
successful in targeting needy populations and
encouraging them to use priority health
services. Great potential in eg.:
- HIV/AIDS prevention in groups most at risk
- Reduction of unwanted pregnancies in young people
Voucher schemes have been successful, also
because they could tap into private sector
resources and engage private providers in
serving needy populations with health care
services they had been unable to obtain before.
Summary conclusion
Vouchers can be a good way to target public
subsidies to specific populations and
encourage them to use priority health
services provided by public and private
providers.
Use of vouchers in conjunction with
franchising may generate stronger returns,
however not much practical experience exists
and experiments on a small scale are needed.