Have health voucher programmes achieved their objectives? This study assesses and synthesises evidence on such programmes’ targeting and their effects on service usage, quality and efficiency, and on people’s health outcomes. It finds robust evidence that health voucher programmes can increase the use of health goods/services and modest evidence that they can effectively target specific populations and improve service quality. Overall, the evidence indicates that voucher programmes do not affect the health of populations. However, this conclusion was identified as unstable by a sensitivity analysis: one additional positive outcome variable would change the conclusion to robust evidence.
One approach to delivering health assistance to developing countries is the use of health voucher programmes, where vouchers are distributed to a targeted population for free or subsidised health goods/services. Voucher programmes are a form of output-based aid, in which aid monies are used to stimulate demand for goods/services.
In a voucher programme there are typically four major actors: (1) the government or donors who provide the funding; (2) a management agency that administers the programme; (3) providers who deliver the health goods/services; and (4) the voucher recipients who are in need of health goods/services. Vouchers are usually competitive, involving multiple providers.
Much of the literature on voucher programmes describes multiple potential benefits of delivering health aid via vouchers. Theoretically, vouchers are expected to successfully target specific populations, increase utilisation, improve quality, enhance efficiency, and ultimately improve the health of populations. There is not, however, a definitive consensus on whether voucher programmes achieve their goals or potential benefits.
This systematic review selected 24 quantitative evaluation studies (evaluating 16 different health voucher programmes) for analysis. Six of the programmes were for insecticide-treated bed net distribution, and nine addressed reproductive health. One general health services programme was also evaluated. Eight of the evaluated voucher programmes were located in Africa, five in Asia, and three in Latin America.
The strongest finding from this review is that the evidence indicates that health voucher programmes have been successful in increasing the use of health goods/services. There is also modest evidence that voucher programmes can effectively target specific populations and can improve the quality of services. While these results are encouraging, the subsequent link that voucher programmes improve the health of the population is not evident in the data analysed in this review.
- Usage: There is robust evidence that voucher programmes were able to increase usage
- Targeting: Modest evidence indicates that voucher programmes were able to effectively target specific populations for health goods/services.
- Quality: There is modest evidence that voucher programmes were able to impact some dimension of quality. (Only three voucher programmes were available for evaluation in this category, instead of the four required for ‘robust’ evidence.)
- Efficiency: There is insufficient evidence to make a conclusion on this outcome category.
- Health impact: Evidence suggests that voucher programmes did not have a significant effect on health outcomes; however, this conclusion was found to be unstable in a sensitivity test. Based on the sub-group analyses, the evidence suggests that voucher programmes delivering health services, those located in Asia, those offering free health goods/services, or those using public and private providers have a positive health impact. Still, due to the instability of the conclusions around health impact, it is too early to place a substantial amount of confidence in these findings.
Future research could usefully focus on four areas:
- A consistent systematic review methodology should be applied to several health financing strategies so that policymakers can examine their relative effectiveness
- A review of lessons learned when implementing voucher programmes is needed
- More evidence should be gathered on the efficiency of voucher programmes and a different approach should be adopted for analysing data on efficiency
- An update to this review should take place in approximately three years’ time to incorporate new evaluations currently underway.