## **9. Simple payment systems**

Most cash-for-service and voucher schemes use fixed payments to pay providers per episode. In the case of the Uganda STI vouchers, however, payments were made per test and procedure, with the result that vetting claims was very complex and back-logs developed in settling them.

## **10. Good collection and use of evidence**

Last but not least, those policies which have been accompanied by strong information systems and regular, high-quality evaluations to inform their development are more likely to have been successful and sustained. The most notable example is PROGRESA, which has been extensively documented and subject to annual evaluations since its start. The evidence of impact has been used to sustain government investment. In the case of Nepal, findings of the implementation evaluation were fed back into improved guidelines and stronger financial systems early on in the development of the SDIP (Powell-Jackson et al. 2007).

# **Strength and weakness of different approaches**

Beyond identifying general pre-conditions for success, are there lessons on the types of roles for which these different mechanisms can best be used? All financing mechanisms’ effectiveness is dependent on purpose, context, and implementation. However, some general strengths and weaknesses are drawn out in Table 5.

Many of the differences noted derive from the scale of implementation: the cash for services policies which are currently well documented are all operated at national scale, for example, while voucher programs tend to be small-scale and receive more focused external technical inputs. A large-scale voucher program – Bangladesh is the key example here – may have more in common with cash for services policies in neighboring India and Nepal than with small-scale voucher programs managed in a limited area by an international NGO or contracted company.

Similarly, the nature of the services themselves is important. Family planning and STI services have very clear outcome indicators and are therefore easy to monitor and evaluate. For delivery care, quality of care and health outcomes are much harder to assess. Having a facility delivery does not in itself indicate how health risks have been affected; there are no gold standards for quality of care measures; and assessing impact on mortality ratios requires large-scale, costly surveys. These will affect how schemes are implemented and how easy it is to provide robust evidence for management and evaluation purposes. These reflections indicate the extent to which the findings in this review are likely to apply to other (non-SRH) services – those with clearly defined services and easily measurable outcomes are more likely to respond well to DSF approaches.

# **Lessons on implementation**

It is beyond the scope of this paper to present detailed lessons on implementation of DSF schemes. Most are complex, and at minimum, require attention to the following additional areas:

**Communication and marketing** – Communication strategies have to reflect the nature of the products and clients. In the Uganda safe motherhood voucher scheme, for example, a combination of community-based sensitization, use of radio, and incentives for distributors was considered effective in

16