SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
October, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
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.
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.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
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.
| 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.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
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.
Effects of voucher programmes for reproductive health services |
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| 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. |
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| 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). |
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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.
Effects of insecticide treated bed net voucher programmes. |
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| 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. |
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| 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) |
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| 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.
|
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.
|
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.
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| 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.
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*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 |
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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.
