A Taxonomy and Results from a Comprehensive Review of 28 Maternal Health Voucher Programmes

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INTRODUCTION

It is increasingly clear that Millennium Development Goal 4 and 5 will not be achieved in many low-income countries (LMICs). According to a recent analysis, at the current rate of change in the neonatal mortality rate (NMR) and maternal mortality ratio (MMR), only 31 countries will meet MDG 4 and still fewer (thirteen) will achieve MDG 5 (1). In many of these countries, the burden of disease and barriers to high-quality healthcare fall disproportionately on lower wealth quintiles (2). Due to these slow improvements in health and the large gaps in equity, there have been calls for global stakeholders to pledge or renew commitments for greater resources and to prioritize strategies that target populations and geographic locations where MMR and NMR are the highest. In addition, there is growing awareness that fostering equitable access to health systems and higher-quality services will figure as significant components in the post-2015 agenda on universal health coverage (3).

The United States Agency for International Development (USAID) held an Evidence Summit in April 2012 to assess the evidence on financial incentives to enhance the provision and use of maternal health services. Financial incentives can be used for accelerating increased coverage, quality, and the use of prenatal and postnatal services and for fostering healthy behaviours during pregnancy and the neonatal period (4-6). A commonly-accepted umbrella term for these approaches is results-based financing (RBF). Related terms include performance-based incentives (PBIs), output-based aid (OBA), and pay-for-performance (P4P) (7). RBF programmes can be characterized by where they place incentives, targeted to either the demand-side or supply-side while acknowledging that demand and supply are intrinsically linked. For the purposes of classification, each type of intervention is labelled according to its unique features that operate on either demand or supply.

In demand-side healthcare financing programmes, the objective is to remove barriers to healthcare-seeking behaviours through economic subsidies. These schemes range from universal with a 'broad' benefits package (e.g. national social insurance) to those targeted with a 'narrow' benefits package (e.g. maternal health voucher programmes). Although removing barriers to the use of services by clients is a central objective, there are anticipated supply-side effects. Healthcare providers are often paid according to the number of clients treated (output-based) or a clearly-defined performance achievement (quality-adjusted output payments). A key feature then is the direct link between the subsidy to the intended beneficiary on the demand side and the desired output on the supply side. In many of these programmes, the focus on demand is justified by historical, persistent unmet needs for specific services [e.g. treatment for sexually transmitted infections (STIs) for socially-marginalized groups or products (e.g. insecticide-treated bednets or contraceptives (8,9).

Given the high levels of inequality observed in maternal and neonatal health outcomes and the use of healthcare, targeted demand-side strategies have the potential to stimulate the use of public health goods and services among the low-income segment of the market where uptake of high-quality health services is often the weakest (2). Vouchers targeted at underserved populations are increasingly used in promoting priority health services and are redeemable for a defined service package at accredited health facilities. Most voucher programmes to date have been designed to increase access to maternal, sexual and reproductive health (SRH) services for those who, in the absence of the voucher, would not have sought care.

To provide guidance to donors and governments who have an interest in launching or expanding reproductive health voucher programmes, this paper presents a taxonomy of knowledge about programme implementation and impact (Figure 1), using a "results chain" to frame the review (10). …