In the late 1970s Pathfinder was one of the first organizations to develop programs supporting the community-based distribution of family planning commodities. Since then, our community-based programs have reached dozens of countries throughout the
developing world. Pathfinder works with communities at the grassroots level to expand access and knowledge, stimulate acceptance, and create awareness and ownership of family planning and reproductive health services
According to the Guttmacher Institute/IPPF in Facts on the Sexual and Reproductive Health of Adolescent Women in the Developing World, some 67 per cent of married adolescent women in sub-Saharan Africa, aged 12 to 19 years, who want to avoid pregnancy are not using any method of birth control. About 12 per cent are using traditional family planning methods including breast feeding, the rhythm (calendar) method, among others. They further state that 42 per cent of unmarried, sexually active women do not use any family planning method.
Reproductive health is a fundamental human right and is pivotal to the well-being of women, men and their families. However, more than 200 million women who would like to delay or avoid pregnancy currently do not have access to modern contraception. A disproportionate number of these women are living in poverty.1
Providing accessible and quality reproductive health services to the poor is critical for countries to make substantial progress towards achieving Millennium Development Goal 5. The increased use of maternity services such as antenatal care, attended deliveries, and post-natal care yield better maternal and infant outcomes (Lawn et al. 2009); increased family planning utilization allows for healthier birth spacing (Yeakey et al. 2009); and timely testing and treatment of sexually transmitted infections (STIs) reduce morbidity and mortality associated with STIs and HIV (Aral et al. 2006).
One strategy for increasing the use of reproductive health services in developing countries is the establishment of voucher programmes where vouchers are distributed for free or highly subsidized reproductive health services and providers are reimbursed for seeing voucher-bearing patients. Much of the literature on reproductive health (RH) voucher programmes has focused on defining the terminology around vouchers and related concepts, describing how voucher programmes work, and detailing the advantages and limitations of voucher programmes.
Typically, voucher programmes are described as a part of consumer-led or demand-side financing, where donor or government funds are used to stimulate demand for services by directly connecting the benefit to the intended beneficiary (Sandiford et al. 2005). Voucher programme monies are linked to outputs rather than inputs and therefore are often referred to as output-based aid programmes (Bhatia & Gorter 2007). These terms refer to monies tied to specific goals, such as the number of services provided, quality indicators, or completion of a specific task (Oxman & Fretheim 2009). With voucher programmes, vouchers are distributed to targeted beneficiaries and subsequently exchanged at contracted providers for RH services. Providers are then reimbursed based on the number of services provided (Sandiford et al. 2005).
There are several advantages to using voucher programmes. First, voucher programmes allow for the targeting of low-income or high-risk individuals in specific geographic areas or according to a means test (Ensor 2004). By focusing on those most in need of services, voucher programmes have the potential to reach individuals who would not otherwise receive reproductive health services.
Second, voucher programmes typically engage the private sector and therefore can introduce greater competition in reproductive health services by increasing supply and improve consumers’ choice (Bhatia & Gorter 2007). Another advantage is that minimum quality standards can be used to accredit facilities and encourage providers who do not qualify to make improvements to become eligible (Sandiford et al. 2005). These improvements can have ‘spillover’ effects improving the quality of care for non-voucher patients too.
Lastly, voucher programmes can facilitate greater transparency through the review of administrative data that track voucher distribution, receipt of services, and performance measures. If information systems are set up properly when designing a voucher programme, providers can be monitored and financially rewarded for providing quality care (Sandiford et al. 2005).
The possibility for fraud at the provider level is one limitation to voucher programmes; however, fraud detection can also be built into a voucher programme, where voucher sales and services are monitored for unexpected spikes or patterns consistent with fraud and patients can be followed up to confirm they received services. Another limitation of voucher programmes is the high overhead costs in the initial stages in order to achieve the advantages detailed above (Bhatia & Gorter 2007).
RH voucher programmes can vary substantially, not only in the services they offer but also in how they distribute vouchers, the conditions under which providers are contracted, and the level of monitoring conducted. At present is that there is a lack of knowledge on the effectiveness of voucher programmes overall and under what conditions they are most appropriate (Bhatia & Gorter 2007; Oxman & Fretheim 2009).
This systematic review examines the evidence on past and present RH voucher programmes. Three questions are addressed: (i) Where and when have vouchers been used for reproductive health services in developing countries? (ii) How have RH programmes been evaluated? (iii) What have we learned regarding RH voucher programmes?