A taxonomy and systematic review of maternal voucher programs: Recommendations for policy, practice and research Ben Bellows 1 , Claudia Morrissey 2 , Elizabeth Higgs 2 , John Townsend 1 , Matta Nahed 2 , Karen Cavanaugh 2 , Jeff Sine 3 , Corinne Grainger 4 , Anna Gorter 5 1 Population Council, 2 USAID, 3 RTI, 4 Options Ltd., 5 consultant
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A taxonomy and systematic review of maternal voucher programs: Recommendations for policy, practice and research
Ben Bellows1, Claudia Morrissey2, Elizabeth Higgs2, John Townsend1, Matta Nahed2, Karen Cavanaugh2, Jeff Sine3, Corinne Grainger4, Anna Gorter5
Growth paradox: Widening inequality within countries even as economies converge
"Countries across Africa [and Asia] are becoming richer but whole sections of society are being left behind.... The current pattern of trickle-down growth is leaving too many people in poverty, too many children hungry and too many young people without jobs."
- Africa Progress Panel, May 2012
Inequitable MNCH services*
• Of 12 MNH interventions in a review of public data across 54 countries, family planning was the third most inequitable
*Barros, A. J. D., Ronsmans, C., et al. (2012). “Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries”. Lancet, 379(9822), 1225-33.
Targeting counterfactual non-users
• Vouchers are intended for poor beneficiaries who, in most cases, would not have used the service if the voucher were not available
Voucher functions (management)• Decide to government-run, contract-out, or franchise• Conduct provider administrative & clinical training (i.e. CMEs)• Design & maintain claims processing & fraud control• Monitor costs, utilization, quality• Offer financial credit to facilities
Missing: cost-effectiveness, administrative-to-service delivery ratio
Knowledge 2 studies Positive effects: increased knowledge of important health conditions.
Missing: measures of community norms and partner knowledge.
Evaluation outcomes (2 of 2)Outcome type
Number of studies
Direction of effect & gaps in research
Utilization 13 studies Positive effects: increased use of ANC, facility deliveries.
Missing: Postnatal care.
Quality 4 studies Positive effects: improved customer care, infrastructure upgrades. Missing: clinical care scores.
Health 4 studies Positive effects: modeled decreases in maternal & neonatal mortality
Missing: sensitivity analysis, DALYs averted
Two challenges: “metrics & scale” … “Or how to know when you’ve had a big, big impact”
• Largest maternal voucher programs operate at $1m-$3m per year
• Deliver 3-5% of all births in Cambodia, Kenya, Bangladesh and Uganda
• Greater efficiency is required if programs are to scale from 3% to 30% of general population
• Needed: routine performance metrics, ideally drawn from operational data (efficiency, quality, equity, DALYs averted)
Acknowledgments Members of the USAID Evidence Review Team 3:
Chair: Claudia Morrissey, USAID
Co‐Chair: Laurel Hatt, Abt Associates
Amy Tsui, Johns Hopkins University Bloomberg School of Public Health
Ana Langer, Harvard School of Public Health
Ben Bellows, Population Council
Bert Peterson, University of North Carolina at Chapel Hill Gillings School of Global Public Health
Craig Lissner, World Health Organization
Hendree Jones, RTI International
Isabella Danel, Centers for Disease Control
Jeff Sine, RTI International
Jessica Celentano, Harvard School of Public Health
John Townsend, Population Council
Karen Cavanaugh, U.S. Agency for International Development
Karen Fogg, U.S. Agency for International Development
Korde, Sonali, U.S. Agency for International Development
Marion Koso‐Thomas, National Institute of Child Health and Human Development
Nahed Matta, U.S. Agency for International Development
Ratha Loganathan, U.S. Agency for International Development
Robert Balster, U.S. Agency for International Development
Saifuddin Ahmed, Johns Hopkins University Bloomberg School of Public Health
Supriya Madhavan, Johns Hopkins University Bloomberg School of Public Health
Ubaidur Rob, Population Council, Bangladesh
Meyer, C., Bellows, N., Campbell, M., & Potts, M. (2011). The impact of vouchers on the use and quality of health goods and services in developing countries: A systematic review (pp. 1–86). London. Retrieved from http://eppi.ioe.ac.uk
Bellows, N. M., Bellows, B. W., & Warren, C. (2011). The use of vouchers for reproductive health services in developing countries: systematic review. Tropical Medicine & International Health, 16(1), 84–96. doi:10.1111/j.1365-3156.2010.02667.x