metadata: authors: 0: author: Somanathan,Aparnaa
1: author: Witter,Sophie
count: World
docna: 0: docna: Demand-side financing for sexual and
            reproductive health services in low and middle-income
            countries : a review of the evidence
docty: Policy Research Working Paper
subtopic: Taxation & Subsidies,Health Care Services Industry,Disability,Reproductive Health,Services & Transfers to Poor,Economic Assistance,Family Planning Research,Access of Poor to Social Services
teratopic: Health, Nutrition and Population,Communities and Human Settlements
abstracts: cdata!: Demand-side financing approaches have
            been introduced in a number of low and middle-income
            countries, with a particular emphasis on sexual and
            reproductive health. This paper aims to bring together the
            global evidence on demand-side financing mechanisms, their
            impact on the delivery of sexual and reproductive health
            services, and the conditions under which they have been
            effective. The paper begins with a discussion of modalities
            for demand-side financing. It then examines 13 existing
            schemes, including cash incentives, vouchers, and longer
            term social protection policies. Based on the available
            literature, it collates evidence of their impact on
            utilization of services, access for the poor, financial
            protection, quality of care, and health outcomes. Evidence
            on costs and cost-effectiveness are examined, along with
            analysis of funding and sustainability of policies. Finally,
            the paper discusses the preconditions for effectiveness of
            demand-side financing schemes and the strengths and
            weaknesses of different approaches. It also highlights the
            extent to which results for sexual and reproductive health
            services are likely to be generalizable to other types of
            health care. It is clear that some of these policies can
            produce impressive results, if the preconditions for
            effectiveness outlined are met. However, relatively few
            demand-side financing schemes have benefited from robust
            evaluation. Investigation of the impact on financial
            protection, equity, and health outcomes has been limited.
            Most importantly, cost effectiveness and the relative cost
            effectiveness of demand-side financing in relation to other
            strategies for achieving similar goals have not been assessed.
repnme: repnme: Demand-side financing for sexual and
            reproductive health services in low and middle-income
            countries : a review of the evidence
display_title: Demand-side financing for sexual and
            reproductive health services in low and middle-income
            countries : a review of the evidence
listing_relative_url: /research/2012/10/16788706/demand-side-financing-sexual-reproductive-health-services-low-middle-income-countries-review-evidence
topicv3: Sexual Reproductive, Maternal and Child
            Health m1327262 639,Cash Transfers m1327437 1608,Family Planning m1327501 1452,Health m1504661 3480,Vouchers m1504820 3553
publishtoextweb_dt: 2012-10-01T00:00:00Z
historic_topic: Health, Nutrition and Population,Communities and Human Settlements
no_of_pages: 43
author_keys: 0: author_key: 807536
1: author_key: 873118
model_extractions: WPS6213 Policy Research Working Paper 6213 Demand-Side Financing for Sexual and Reproductive Health Services in Low and Middle-Income Countries A Review of the Evidence _Sophie Witter Aparnaa Somanathan_ The World Bank East Asia and the Pacific Region Human Development Department October 2012
Policy Research Working Paper 6213

# **Abstract**

Demand-side financing approaches have been introduced in a number of low and middle-income countries, with a particular emphasis on sexual and reproductive health. This paper aims to bring together the global evidence on demand-side financing mechanisms, their impact on the delivery of sexual and reproductive health services, and the conditions under which they have been effective. The paper begins with a discussion of modalities for demand-side financing. It then examines 13 existing schemes, including cash incentives, vouchers, and longer term social protection policies. Based on the available literature, it collates evidence of their impact on utilization of services, access for the poor, financial protection, quality of care, and health outcomes. Evidence on costs and cost-effectiveness are examined, along with analysis of funding and sustainability of policies. Finally, the paper discusses the preconditions for effectiveness of demand-side financing schemes and the strengths and weaknesses of different approaches. It also highlights the extent to which results for sexual and reproductive health services are likely to be generalizable to other types of health care.

**It is** clear that some of these policies can produce impressive results, if the preconditions for effectiveness outlined are met. However, relatively few demand-side financing schemes have benefited from robust evaluation. Investigation of the impact on financial protection, equity, and health outcomes has been limited. Most importantly, cost effectiveness and the relative cost effectiveness of demand-side financing in relation to other strategies for achieving similar goals have not been assessed.

This paper is a product of the Human Development Department, East Asia and the Pacific Region. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://econ.worldbank.org. The author may be contacted at asomanathan@worldbank.org.

_The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent._ Produced by the Research Support Team
**Demand-side financing for sexual and reproductive health services in low and middle-income countries: A review of the evidence** Sophie Witter<sup>a</sup>

Aparnaa Somanathan<sup>b</sup> a Research Fellow & FEMHealth Coordinator, Immpact, University of Aberdeeen, AB25 5ZD, UK. Email: <u>s.witter@abdn.ac.uk. Corresponding author. Tel. +44 1943 604413.</u> b Aparnaa Somanathan, World Bank Task Team Leader for the Results Based Financing Knowledge and Learning Grant to the East Asia Pacific Region, The World Bank, 1818 H Street, NW, Washington, DC 20433 USA. Email: asomanathan@worldbank.org. Tel: +1 202 473 1000.

Key words: demand-side financing, reproductive health, health financing, demand constraints JEL classification: health, education and welfare Sector Board: HNP
**Demand-side financing for sexual and reproductive health services in low and middle-income countries: A review of the evidence**

# **Introduction**

In recent years, demand side financing (DSF) mechanisms have been piloted and implemented in the health sector in several countries around the world. They have been attempted in a wide range of settings, from middle-income countries with relatively good governance and strong performance monitoring systems to low-income countries with fragile health systems. Questions remain, however, about their feasibility, effectiveness and sustainability in different contexts. In particular, there is little understanding about the pre-conditions, institutional as well as economic, for their success.

The term DSF is used in different ways in different studies (Gupta et al. 2010). We have defined DSF as actions which transfer resources to households on condition that they utilize specific services. There are three possible objectives for this:

1. The first is to change the kind of services which are consumed. Assuming the services are public health goods with external benefits or merit goods, increasing their consumption will increase allocative efficiency in the sector.

2. The second is to improve equity by focusing transfers on specific disadvantaged and under-utilizing groups, increasing their consumption of services.

3. Finally, there can be an objective of promoting choice between suppliers for services, and hence competition, with the aim of improving quality and technical efficiency.

The mechanisms through which DSF might work are two-fold – first, incentivizing behavior change (for consumers, but also indirectly for suppliers of services), and second, by increasing the affordability of specific services (as a result of cash transfers or near-cash transfers, such as vouchers).

Although the term is used in a variety of ways, it follows from this definition that DSF is distinct from the following (closely related) approaches:

- Unconditional cash transfers, which increase income levels of targeted groups and hence affordability of services, but without tying transfers to specific service use

- Fee exemption, which increased affordability of specific services, but using a supply-side approach (channeling resources through providers)

- Insurance approaches, which can provide protection against health care costs for specific groups, but are not conditional on specific behaviors

- Changes to provider payment systems, such as capitation, which may influence consumer choice but cover a wider package of services and use a supply-side payment mechanism

Some reviews exist of different DSF modalities, such as conditional cash transfers (Lagarde et al. 2007). This paper aims to bring together existing evidence on all DSF mechanisms in relation to sexual and reproductive health (SHR) in low and middle-income countries. SHR services have been a major focus for DSF, largely driven by concern about Millennium Development Goals targets for maternal health, which continues to pose a global challenge. The paper aims to synthesize evidence on the design and scale of existing schemes, their impact on the delivery of sexual and reproductive health services, and their cost 2
and sustainability. From this we draw policy lessons on different modalities and the conditions under which they have been effective, as well as identifying outstanding research gaps.

# **Research methods**

This paper is compiled based on a literature review carried out in November-December 2010. Search terms included demand-side financing, or vouchers or cash transfers _and_ reproductive health or sexual health or maternal health or deliveries or obstetric care or family planning or neonatal care or antenatal care or postnatal care or sexually transmitted infections. In addition, we ran individual searches for programs by country or name of program (when known). Google Scholar, PubMed, SSRN, World Bank Imagebank and other library resources were searched.

The results reflect some of the better documented schemes – they are not definitive, and there are more recent programs which are either still in pilot phase or not well documented. Much of the existing literature is ‘grey’ – agency reports, which are not yet published in peer-reviewed journals. We have focused on recent interventions relating to sexual and reproductive health. There are a number of studies on vouchers for insecticide-treated bed nets, for example; however, as the main health benefits relate to children, these have not been reported here. Similarly, studies of conditional cash transfer (CCTs) which focus, say on education, but have side-effects in terms of sexual behavior are not included. Older schemes, such as the vouchers for family planning in Korea and Taiwan, China in the 1960-70s, are not described here but can be found in Bellows et al. 2010.

# **Results**

## **Modalities for DSF**

There are three main types of DSF (Walford, 2008):

1. Cash transfers paid when a service is taken up. For these schemes, such as the Safe Delivery Incentive Programme in Nepal (now named Aama), the cash tends to be more limited and is focused on covering service and/or access costs<sup>1</sup> .

2. Vouchers that can be used to cover all or part of the cost of specified health services, such as for Sexually Transmitted Infection (STI) treatment in Uganda. These near-cash benefits have a similar objective to the first mechanism but can be marketed in different ways (including social marketing and subsidized sale). They often emphasize choice of provider more than direct cashfor-services.

3. Longer term income support linked to take-up of education and health services. These schemes, such as the conditional cash transfers (CCTs) in Latin America, function more as social protection mechanisms. Although there is conditionality linked to specific service uptake, they have a more significant impact on overall household incomes and a wider poverty-alleviation objective.

> 1 For the main references for the schemes which are analysed in depth, see Table 1. All schemes which have been documented in any detail are included in the tables.

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## **Targeting**

Although it is generally assumed that DSF are targeted to specific income groups, this is not necessarily the case – in Nepal, for example, cash incentives were offered to all women, although with varying sums based on location. In the Janani Suraksha Yojana (JSY) in India, a mix of geographical and income targeting is used. For larger social transfers, such as in Latin America, income targeting is more essential, because of their aim and scale. For voucher schemes, such as the STI treatment vouchers in Nicaragua, specific client profiles can be adopted – this scheme, for example, targeted sex workers and their partners.

## **Fully free or subsidized**

In terms of benefits to households, the cost of services is usually fully covered by the schemes, but some vouchers are sold at a high subsidy, so that households make a small contribution. As well as reducing costs, DSF also aims to increase their predictability.

## **Demand- versus supply-side financing**

Although the label of DSF implies that it is an alternative to supply-side (traditional) financing, this is not generally the case. In most schemes, ongoing public financing of services is unchanged, and the DSF component is supplementary or replaces user fees revenues.

## **Payment mechanisms**

For vouchers and cash-for-services (as opposed to the broader social protection form), the payment mechanism for providers is output-based, with an agreed tariff for each type of service delivered in most cases (though one scheme reports using fee for service payments).

## **Complementary elements**

In some cases, the DSF is complemented by payments to providers for performance and/or fee exemptions. In the Nepal Aama program, all three components of cash payments to women, incentive payments to health workers, and free delivery care are present. In other cases, the DSF may be complemented by insurance aimed at the poor which covers other services (this is the case in a number of Latin American countries). In the case of vouchers for goods, such as family planning, social marketing of products may run alongside the DSF activities.

## **Organizational context**

A DSF requires autonomous fund management capacity, which is undertaken in many schemes by a purchasing body, third party organization or external donor. However, this is not necessary, and in some cases the funds are managed by the line ministry.

## **Provider types**

The providers participating in a DSF scheme can be public, private and private not-for-profit, depending on their availability, capacity, quality and cost in any given context.

# **Scale and scope of DSF**

There has been a proliferation of DSF in recent years, with many of the schemes focused on SHR. An overview of some of the schemes is given in Table 1.

4
The scale of implementation is very varied – many are national policies, with nationwide implementation, whilst others are more limited, and often supported by external partners. A brief description is given here of some of the main schemes.

# **Cash incentives**

There are two major national cash incentive programs currently described in the literature, both encouraging facility-based deliveries, in India and Nepal, although other as-yet-undescribed programs are starting in a number of other countries, such as Zambia.

In India, the Janani Suraksha Yojana (JSY) program was launched in 2005 to increase institutional delivery among the poor and hence reduce maternal mortality<sup>2</sup> . It is a nationwide program with central funding, but focussed on the states with low institutional delivery rates. Local associations or health workers are encouraged to identify women and support their access to a full package of pregnancy care, using a birth micro-plan. Cash assistance is available to all women in low-performing states delivering in public institutions or accredited private institutions, and to women over 19 and below the poverty line in higher performing states. Scheduled caste and scheduled tribe women receive support whatever the area in which they live. The tariff of payments is higher for rural than urban areas, to allow for higher transport and lodging costs, and includes an incentive payment to health workers in low-peforming states. The cash is provided by the health institutions, generally at the time of the delivery. The service itself is supposed to be provided without charge in public facilities.

For deliveries in private facilities, women receive cash but are not entitled to free delivery services, nor are the health workers eligible for the incentive payments. In low performing states, there is no limitation on the number of births, while in high performing ones, the limit is two live births. Caesarians are carried out free of cost, but where no public facility is available, assistance is provided to fund private care. For poor women who choose to deliver at home, are over 19 and have had fewer than two live births, Rs 500 is made available to support their costs. Some financial support is also given to women who volunteer for sterilization immediately after delivering.

In Nepal, the Safe Delivery Incentive Programme (SDIP) was also launched in 2005. The package of financial benefits offered by the SDIP sought to change the behavior of both families and health workers. The level of cash incentive offered to women was set to reflect differences in geographical accessibility to health institutions across regions, covering between a third and a half of the transport cost. Initially, free care was available in districts with a low human development index score. In January 2009, this was extended to all areas of the country, with the new Aama program (which combined fee exemption with the existing cash payments).

Since then, a range of DSF has been developed in Nepal, including for ANC, PNC, and uterine prolapse, as well as for PMTCT, multi-drug resistant TB and HIV/AIDS<sup>3</sup> . At present, women receive $7 in transport payment for deliveries in lowland areas, $14 in the hills and $21 in the mountains. The same payments are made for women undergoing treatment for uterine prolapsed. For women who have completed four

> 2 This information is taken from the Ministry of Health website.

> http://mohfw.nic.in/dofw%20website/JSY_features_FAQ_Nov_2006.htm

> 3 Scoping report for the National Health Sector Support Programme, Witter & Prasai, December 2010

5
or more ANC visits, an additional $2.2 is paid, and there is piloting of payments for those who complete three PNC visits ($4.2).

# **Vouchers**

Voucher programs are typically implemented on a smaller scale – aimed at specific groups and specific areas, and in all cases with external funding and technical support. Services covered have included maternal health care (ANC, deliveries, PNC), family planning, treatment of STIs and counseling and treatment of gender-based violence. There are currently also two pilots being undertaken in Malawi and South Africa using vouchers for male circumcision (Boler and Harris, 2010).

KfW has recently been supporting the use of vouchers for family planning and delivery services in Kenya and Uganda. Vouchers are offered for sale at a highly subsidized rate (200 Shillings per delivery in Kenya – around $2.5). To identify members of the target group, a participatory poverty grading tool was developed for the four targeted Kenyan districts. The tool is district-specific and includes eight indicators (housing, access to medical facility, water source, rent amounts, sanitation, income levels, and number of meals taken per day). A score rate of between 8 and 16 points qualifies the person one to purchase the voucher. Providers are a mix of public, private and NGO-based.

Under the World Bank-funded Poverty Action Fund in China, poor households in Yunan province were given MCH vouchers to cover the user fees for specific categories of mother and child health care, including routine pre- and post-natal care, hospital delivery care for high-risk pregnant women; and first aid for severe obstetric complications. The vouchers were collected by facilities and sent to the provincial headquarters for reimbursement. The very poor and poor (14% of the population) were identified through village councils (Kelin, Kaining, & Songuan 2001). Further data on this program has not been identified however.

In Bangladesh, a voucher scheme for maternal health care was piloted by UNFPA and WHO. The vouchers were distributed to households below a certain income threshold, entitling them to free deliveries for their first and second pregnancies, subject to adopting family planning. This was later rolled out by the government in 2007 to 33 sub-districts (in some using targeted vouchers and in others universal ones). Under the Maternal Health Voucher Scheme, target women receive vouchers for three ANC check-ups, safe delivery at a facility or at home by skilled birth attendants, a postnatal check-up within 6 weeks of delivery and management of complications including caesarean section from designated providers. They also receive transportation costs for accessing the covered services.

Vouchers for maternal health have also been used in some districts of Cambodia, alongside a range of other measures such as health equity funds and contracting of services. There have also been pilot projects in Indonesia and Pakistan, and a longer-standing voucher scheme for private provision of delivery care in Gujurat state, India.

In Nicaragua, a voucher scheme has been implemented to increase the prevention and treatment of STIs in high-risk groups, such as sex workers(Sandiford, Gorter, & Salvetto 2002). A reproductive voucher scheme was also supported in Managua in 2000 (Meuwissen, 2006).

6
### **Social transfers**

The social transfer approach has been developed extensively in Latin America. The focus of most of the programs has been on child health, educational attendance and, to a lesser extent, preventive care for mothers. Reproductive health is therefore only a small strand within the studies. In recent years, the model has been exported to Asia, with pilots established in Indonesia and the Philippines.

The best known example is the PROGRESA program (later Opportunidades) in Mexico, aimed at improving children’s education, health and nutrition through conditional cash transfers. Low-income families were given a subsidy on condition they obtained a range of health services including nutrition monitoring and supplements for children and lactating mothers, growth monitoring for the under-fives, antennal care and child immunizations and attended various adult health promotion clinics (Gertler, 2000).

Honduras has operated a family allowance program – a scheme distributing freely exchangeable vouchers through primary schools or the program itself for antenatal (ANC) visits, perinatal checkups, and monthly well-child checkups (Morris, et al. 2004a). This is part of a wider social protection system, providing montly income, and is therefore included under social transfers, despite using a voucher mechanism.

Brazil has been operating the ‘Bolsa Alimentacao’, a scheme providing cash payments via magnetic debit cards to be used at automatic teller machines or lottery ticket sellers for antenatal care visits, monthly well-child checkups, immunization and growth monitoring services (Morris, et al. 2004b). Although ANC is included, the focus of this intervention is improving child health. Similarly, Bolivia has a cash transfer scheme, available to all households in 70 rural districts with a pregnant woman or young child, conditional on their use of preventive services (Morris & et al. 2004).

# **Evidence of impact**

The quality of evidence varies across different projects and policies – some have been subject to fairly rigorous impact evaluations (e.g. the JSY in India and the SDIP in Nepal, as well as the Bangladesh and Nicaragua vouchers schemes, and the social transfers in Mexico and Honduras), while others rely on internal project data or administrative sources to assess impact. A summary of results is given below, but giving more weight to the more robust studies.

## **Utilization of services**

Raising the utilization of specific services is a core aim of the DSF policies, and this output indicator is reported in all studies (see table 2), though with varying degrees of adjustment for other influencing factors. Unsurprisingly, given the policy mechanisms, all report increased utilization, although the degree of response is sometimes lower than expected, suggesting either low price elasticity of demand, poor implementation of policies and/or the presence of other (non-financial) barriers to service use.

7
Studies often fail to assess the degree to which increases reflect switching by users (e.g. from private to public services). Possible spillover effects on non-targeted groups are also often ignored.

# **Cash incentives**

A process evaluation found that there was evidence to suggest that institutional deliveries had increased due to the JSY in India (Devadasan et al. 2008). However, it was apparent that there are some weaknesses in the scheme. Women were not aware of the scheme in some states. Changes in the benefits were promoting home deliveries, which conflicted with the original objective of encouraging institutional deliveries to reduce maternal and neonatal deaths. The authors also concluded that documentation procedures had evolved into a cumbersome process and had the potential to deny benefits to the needy.

An impact evaluation of the JSY found that implementation was highly variable by state—from less than 5% to 44% of women giving birth receiving cash payments from JSY (Lim et al. 2010). The poorest and least educated women did not always have the highest odds of receiving JSY payments. It found that the JSY had a significant effect on increasing antenatal care and in-facility births.

An evaluation report found that implementation of the SDIP in Nepal had been well below the target level of paying all eligible beneficiaries but was showing promising signs of improvement over time (Powell-Jackson et al. 2008). Women exposed to the SDIP were 24 percent more likely to use government health institutions, 5 percent less likely to deliver at home and 13 percent more likely to have a skilled attendant at delivery. However, there was no evidence that the SDIP increased use of lifesaving obstetric surgery (caesarean sections).

# **Vouchers**

All voucher schemes reported increased utilization – for example, an increase of 21% in institutional deliveries was recorded in the first year of implementation of the Chiranjeevi Yojana policy in Gujurat (CYG), India. In the Bangladesh voucher scheme, women living in areas with universal entitlement were found to be 26% more likely to deliver in a health facility, while those in targeted areas were 13% more likely (and no difference with control areas was found for caesarean sections).

For the STI vouchers in Uganda, there was a 15% increase in utilization of treatment services in the first two years, but skewed toward those living within 10 km of facilities. A more closely targeted voucher scheme aimed at sex workers and their partners and clients in Managua produced a more dramatic increase in treatment of the four most common STIs – up from 15% before the project to 92% afterwards. For sexual and reproductive health care vouchers distributed to adolescents in Managua, 34% of voucher recipients used these services, compared with 19% of non-receivers, leading to a higher use of modern contraceptives and condoms.

However, use of vouchers is sometimes low, especially for delivery care where access and cultural factors play an important role. A recent study of the combined effects of vouchers and health equity funds in some districts of Cambodia concluded that vouchers had increased facility utilization and had brought to facilities pregnant women who had previously delivered at home (Por et al. 2008). However, 8
uptake was disappointing – less than 50% of women who were given vouchers used them for delivery care.

## **Social transfers**

The social transfers were focused on child health and education services and have had modest reported impact on use of ANC. In the case of the Mexico and Honduras policies, this was one of the conditional services on which receipt of funds depended, so an increase in utilization would certainly be expected, although the degree to which conditionality was monitored and enforced is reported to have varied across schemes (PAHO/WHO 2007). It is also noteworthy that despite its proven importance to mother and child health, none of the Latin American conditional cash transfer schemes included facility deliveries in their conditionality, perhaps because they were covered by health insurance programs for the poor.

No difference in antenatal care (ANC) utilization was found in rural areas in the first phase of PROGRESA, though for the second phase in urban areas, ANC increased by 6%. A study focussing on family planning (FP) uptake (Feldman et al. 2009) found that the ‘treatment group’ were more likely to use modern contraception, but had no difference in birth spacing and were no more likely to deliver in a health institution. In Honduras, an increase of 18% in ANC was recorded in a trial related to the policy (Morris et al. 2004).

# **Access to services for the poor**

For many of the schemes which are targeted at poor households (identified through a variety of criteria and channels), analysis of the distribution of benefits or differential impact on access by different groups has not been conducted, perhaps on the assumption that they can be assumed to be pro-poor. Where analysis has been done, universal schemes have tended to benefit middle-income households disproportionately in the cash incentive schemes. Targeted schemes (where analysis is available) report under-coverage of their target group in some cases (e.g. the CY in Gujurat), while in others there is considerable ‘leakage’ (e.g. 40% o the top two quintiles receiving vouchers in the Honduras BMI, and 49% of women in the top two quintiles in Bangladesh receiving maternal health vouchers).

## **Cash incentives**

For the JSY in India, implementation has varied considerably across states, but the national evaluation found that women of middle wealth and middle income were most likely to benefit from the scheme (Lim et al 2010). In rural areas, those living close to facilities were more likely to benefit. In relation to equity, the impact of the SDIP in Nepal on utilization of skilled birth attendance was also greatest among women of average wealth (middle wealth quintile) (Powell-Jackson, Neupane, Tiwari, Morrison, & Costello 2008). Women exposed to the SDIP and in the middle wealth quintile were 93 percent more likely to use government delivery care services and 66 percent more likely to use a skilled attendant at delivery. While the impact was slightly less among the poorest two-fifths of women, they were still 64 percent more likely to use a skilled attendant at delivery. In contrast, there was no evidence that the 9
SDIP had any impact on skilled birth attendance among the richest two-fifths of women. For these women, the SDIP simply encouraged them away from NGO or mission health institutions (where available) into government health institutions.

Inequality in the use of delivery care services provided by government health facilities means that the recipients of the cash incentive are disproportionately richer households. This is to be expected since there is no specific targeting of poorer households in the SDIP. Among women who were eligible and meant to receive the money, women with no education, unaware of the SDIP, living more than one hour from the health institution and Dalits were less likely to receive the cash.

## **Vouchers**

Most studies of vouchers schemes do not analyze differential uptake. For the STI voucher scheme in Nicaragua, there was no analysis of coverage of the target group, but the poor and those with more STIs were reported to be more likely to use their vouchers. For the Bangladesh MHV scheme, it contributed to reduced inequity in facility deliveries, but 49% of women in the top two quintiles benefited, even in targeted areas. By contrast, the Gujarat vouchers were well targeted but failed to cover all of the poor.

## **Social transfers**

Targeting of PROGRESA has been effective: 80% of its beneficiaries were estimated to be in the poorest 40% of the population (Gwatkin, Bhuiya, & Victora 2004), although later studies indicate that this may have dropped to 60%. It is very different in scale compared to many of the other DSF policies, however, covering 40% of rural households. Moreover, its targeting costs are substantial - estimated at 30% of total costs (Gertler 2000). For the Honduras BMI, it is reported to have reached 84% of its target group, but with 40% of beneficiaries in the top two quintiles.

# **Financial protection**

Reproductive health costs can be significant for households. However, while DSF schemes aim to improve the affordability of specific services, very few evaluation studies examine the impact of the policy on household spending on reproductive services or health care in general.

## **Cash incentives**

The SDIP evaluation (Powell-Jackson, Neupane, Tiwari, Morrison, & Costello 2008) is an exception: it concludes that the cash incentive protects a small proportion of households from catastrophic expenditure but fails to protect households from being forced into poverty that results from delivery care payments. In one district, Makwanpur, the cash incentive represented less than 20 percent of outof-pocket expenditure on institutional delivery care, an inadequate amount to reduce the impoverishing effects of these health care payments. In India the JSY scheme covered less than half the costs of women. In addition, around a third of women reported not having received the incentives (Lim et al. 2010).

## **Vouchers**

In general, vouchers are reported to have reduced user costs for services (unsurprisingly), but the significance of this in relation to household incomes or expenditure is generally not assessed. For the Bangladesh scheme, lower out-of-pocket payments by beneficiaries were recorded; however, only 6010
65% of women reported receiving their nutritional cash incentive (the largest component of the cash payments due to them) (Hatt et al. 2010).

## **Social transfers**

Financial protection is not assessed directly for the social transfers, but the value of the overall transfer is known – around 20% of average household consumption in Mexico, but much lower in Honduras (4%). As services are free, the aim of these transfers is poverty alleviation (with conditionality), rather than financial protection against health care costs per se – at least in the Mexican policy. For Honduras, the lower level transfer might more appropriately be seen as compensation for the opportunity costs of accessing services.

# **Quality of care**

A number of the studies – in India, Nepal and Bangladesh, for example - highlighted poor quality of care or supply side constraints (such as inadequate staffing and services), before as after the introduction of the DSF schemes (Table 3). Clearly, a DSF approach presupposes that services are available, accessible and able to offer a reasonable quality of care – otherwise higher utilization is likely to be ineffective or even positively dangerous. For that reason, a number of interventions were accompanied by supply-side measures to upgrade services. These included provider incentives, training, and upgrading of facilities in some cases.

In only a few cases were checks done to assess the technical quality of care. In the Uganda RH voucher scheme, the proportion of correct treatments was high, especially for the more common STIs. In the Nicaragua STI voucher program, simulated patients were used to assess quality of care, and this demonstrated some improvements following the start of the program (although some indicators dropped again after the program stopped).

Improvements in quality of care rely on DSF schemes either increasing consumer choice pressures (where there are alternative providers of reasonable quality available) or the schemes adding significant resources for providers. Where there is choice, accreditation mechanisms can also be used to ensure that only providers of a certain standard are reimbursed under the scheme. However, there often is no effective choice either because providers do not sign up to the scheme because the reimbursement level is insufficient (private providers are often not keen for this reason) or because there is a limited range of providers in a given area. The rapid review of the Bangladesh voucher scheme, for example, found there was little evidence that the mechanism encouraged competition due to the limited provision of health care services (Schmidt et al. 2010). It concluded that the voucher scheme provided substantial additional funding to facilities but remained complex to administer, requiring a parallel administrative mechanism which put an additional work burden on the health workers.

# **Health outcomes**

Measuring health outcomes gains and attributing them to the DSF intervention is ambitious and many studies (e.g. Nepal, Kenya, Gujarat) do not attempt to do this (see Table 3). In other cases, positive trends are noted but cannot be attributed with confidence to the policy (Bangladesh and Indonesia). For some policies (e.g. Honduras), no health gains were found by evaluators.

For some of the policies, improved user knowledge is an important outcome – this is reported, for example, in the Nicaragua STI and SRH voucher programs. In the Nicaragua STI voucher scheme, declines 11
in rates of syphilis and gonorrhea are reported (Sandiford, Gorter et al., 2002), as is also the case for the Ugandan RH vouchers, where a 42% drop in syphilis prevalence was found in the first year (Bellows and Hamilton, 2009).

The JSY payment was associated with a reduction of 3.7 in perinatal deaths per 1,000 pregnancies and 2.3 neonatal deaths per 1,000 live births, but no significant impact on maternal mortality could be detected using that sample size (Lim et al. 2010).

In Mexico, cash transfers alongside information, micro-nutrient supplementation, weight monitoring etc brought about higher birth weights and improvements in child nutritional status, especially stunting.

# **Costs and cost effectiveness**

## **Total costs**

Total cost information is available for most (8 out of 13) of the policies which are studied in depth (see table 4). The different scales of the DSF policies is illustrated by comparing the size of their budgets, ranging from $60,000 per year to provide vouchers to a specific client group in one city (the Nicaragua STI scheme) to $3.6 billion for the PROGESA/Opportunidades program in Mexico, which enhances the income of an estimated 25% of the country’s population.

## **Cost breakdown**

Costs are hard to compare, given the different packages being offered. However, the proportion of spending which comprises overhead costs is of interest, as one measure of efficiency (although some overhead costs can be very productive – for example, investments in training of providers or communication to clients can be effective interventions in their own right). Not all studies report overhead costs and classifications vary, but the available information is nevertheless illuminating.

For the national JSY policy in India, implemented through the national health system, the overheads are limited to a total of 11%. For Nepal, the proportion is not reported. The proportion is likely to be relatively low; however, implementation difficulties may be a reflection of under-investment in strong administrative systems in both of these cases.

Two voucher schemes in neighboring countries – both in their start-up phases – nevertheless had overhead costs of 21% in one case (Kenya) and 72% in the other (Uganda). For voucher schemes, a complicated array of administrative structures is needed for voucher management, accreditation of providers, voucher distribution, setting reimbursement rates and claims processing. These are costly and require developed management capacity (in Kenya, an international management consultancy firm was hired to provide voucher management functions). It is not clear however why there is such a divergence between the two schemes.

A systematic review of conditional cash transfers found that the value of the transfers constituted a mere 4% of overall program expenditure for the Mexican scheme, 8% in Nicaragua, 16% in Columbia 12
and 28% in Honduras (Lagaarde, Haines and Palmer, 2007). Targeting, conditioning, and administrative costs are amongst the overhead categories.

## **Cost effectiveness**

None of the studies examined the cost-effectiveness of their DSF interventions, with the exception of the Nicaraguan STI voucher scheme, which was found to be cost-effective, with a lower cost per STI patient effectively cured costs compared to before ($118 compared to the status quo of $200).

# **Funding and sustainability**

There is a correlation between the level of development of a country and the funding of their DSF policies – by and large, low income countries have external funding, while for low and upper middle income countries, some or all of the funding comes from local sources. Some policies are quite ambitious: in Mexico, the overall Opportunidades policy absorbs 45% of the entire federal anti-poverty budget (Barber and Gertler, 2008), while in India, almost half of the federal budget for maternal health is now absorbed by the incentive scheme (Walford, 2004). As many of the policies are young, it is hard to assess at this stage their likelihood of being sustained, and indeed it is not yet clear how long they should be maintained in order to meet their objectives. There is a risk that after 2015 many of the policies focused on improving maternal health may lose support.

# **Discussion**

## **Preconditions for effectiveness**

A number of factors for success of these reproductive DSF policies are drawn out here, not necessarily in order of importance.

**1. Correct identification of demand-side barriers to use**

DSF approaches will work best when services are underutilized by the target group for reasons which are predominantly financial.

DSF works on the asumption that supply-side subsidies provided by government may not be effective at targeting those in most need. There is strong evidence that the poor have inferior access and make lower use of publicly allocated resources and services (Demery 2000, Institute of Policy Studies 2001, van Doorslaer, et al. 1993). This is for a variety of reasons, however, many of which are non-financial, including poor physical access to facilities, ignorance of treatment options, poor treatment by providers, and other constraints (cultural, gender, ethnic, caste etc.) preventing health seeking behaviour. Where non-financial barriers predominate, alternative policies may be more effective, or complementary actions to address these wider factors are likely to be necessary to make DSF schemes effective. Reproductive health is an area where social and cultural factors tend to play an important role in health seeking choices.

The assumption that improving the affordability of the service alone will raise demand does not always hold. In the case of Cambodia, the low utilization of delivery vouchers (which covered the full range of costs, including transport) raised the issue of cultural perceptions and other (non-price) barriers.

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Interviews with non-users revealed that concerns about finding transport to facilities, about poor staff attitudes in facilities and about taking care of their household were responsible for women not using their vouchers (Por et al. 2010). For the Kenya voucher scheme, a range of marketing strategies had to be developed – what worked in rural was different for urban areas (Bellows et al. 2009). In Pakistan, in addition to distributing vouchers, the project invested in communication activities, meeting with women, and providing testimony from women who had used services to break down cultural barriers. Three to four visits were needed per household to develop trust, deal with doubts and sell the voucher (Bashir et al. 2009).

In addition, the way in which vouchers are distributed and to whom may affect their effectiveness, especially when there are different preferences, for example in a household. In a randomized trial of FP vouchers in Zambia, vouchers given to women individually had a significant effect in terms of uptake, adoption of FP and unwanted births avoided, whereas vouchers given to couples had no effect on unwanted births avoided, compared to the control group (Ashraf et al. 2010).

# **2. Adequate supply-side capacity and quality**

Clearly, adequate services must be in place if DSF is to be effective in raising utilization and improving outcomes. In Nepal, for example, the roll-out of the SDIP was accompanied by considerable other investments in establishing and equipping birthing centers and improving training of staff, amongst other activities. An underutilized health system, functioning reasonably well, with competition between different suppliers, is the ideal context for introducing a DSF scheme.

The introduction of DSF therefore involves an assessment of the state of the existing services, and potentially supply-side investments in raising standards prior to inflating demand. This should focus on the accessibility of services, the availability of services (staffing, opening hours etc.), having adequate infrastructure (equipment, buildings, drugs etc.), appropriate processes (infection prevention etc.) and management (staff workload, supervision etc.

# **3. The right economic conditions**

Many DSF schemes are externally funded and longer term funding will be needed to ensure their sustainability. In Nepal, for example, the SDIP was initially fully funded by DFID. Over time, the aim is to transfer the funding responsibility to the Government of Nepal, which will however be challenging. Countries which have sustained large-scale and enduring DSF policies, such as Mexico, have tended to be middle-income countries, which meet the preconditions of having reasonable state capacity to target and manage policies, the ability to finance more far-reaching transfers, a smaller proportion of their population living in poverty, and a reasonable network and standard of services (Cechini, 2009).

# **4. Appropriate design of package**

Services which are unpredictable, in terms of demand or need, are not easily accommodated in a DSF, Preventive care is favoured not only because it averts future costs for individuals and the public purse, but also because coverage goals are clear and greater consumption is generally good. For most reproductive health interventions, the identification of the target group is relatively easy, and their need for services predictable. One area for careful monitoring however is emergency obstetric care, which can be inflated or provided to the wrong group (women without clinical indications) if there is a financial incentive for providers.

Another factor is the cost of the goods and services. If the cost is very low (for example, the price of purchasing condoms as a family planning method), then a relatively expensive delivery mechanism, such 14
as vouchers, is unlikely to be justified. However, offering access to longer terms, less affordable FP methods may be worthwhile.

Another important decision is whether to include non-facility costs (for vouchers and cash linked to services). Where travel costs are very high (as was the case in Nepal) and where schemes target the poorest, these costs should ideally be included.

# **5. The right size of transfers**

The size of the subsidy has to be adequate to motivate behaviour change (Chapman, 2006). On the other hand, payments which are excessive are wasteful and may be benefiting those who would in any case have used services. The level of subsidy can be established iteratively through pilot projects, if these are carefully monitored.

# **6. Motivated and incentivized suppliers**

If health workers are underpaid and under-motivated, then DSF schemes will exacerbate these problems through increasing their clinical and administrative workload (and in some cases undermining the payments which they previously received from clients). In such contexts, schemes have been most effective when combined with complementary measures to address supplier incentives. In Cambodia, for example, areas with performance-based contracting and provider incentive payments performed better than those with demand side measures (vouchers and health equity funds) alone (although the incremental cost-effectiveness of each component was not assessed and would be interesting to know). However, provider incentives should be carefully designed to avoid distortions in services provided (e.g. promoting FP services which are lucrative rather than respecting client choices).

# **7. Strong political leadership**

Given the complexity and cost of many DSF schemes, ultimately there has to be considerable political commitment to sustain them. Some of the studies highlight the importance of an influential local champion (e.g. Bellows & Hamilton, 2009; Ensor, Clapham, & Prasai 2008).

# **8. Institutional capacity**

The managerial complexity of some of the schemes is evident. Systems for identifying beneficiaries, communicating schemes, channeling funds, and monitoring must be strong. If funds are not available on time, the credibility of the whole project is undermined for beneficiaries. Considerable technical support and iterative development of systems is needed. Where this develops wider systems capacity, it may have side-benefits beyond the project. However, where external agencies manage the project, the systems benefits are less clear.

Handling of cash also involves financial risks which have to be managed. In Nepal and India, cash was managed by health staff and there is evidence of some degree of misuse. One rapid review of the SDIP, for example, found that 8% of incentive payments to health workers for institutional deliveries were fraudulent (CREHPA, 2008). For payments to staff conducting home deliveries (which are much harder to verify), the rate was much higher.

Targeting of the poor is also a demanding activity, requiring both resources and institutional capacity, although in states where there is already an established poverty identification system (such as the BPL cards in India), then targeted schemes are more feasible and potentially efficient.

15
## **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
increasing uptake. In a Pakistan family planning voucher program, it was important to use trusted community members to address widely held misconceptions about the products (Boler and Harris, 2010).

**Quality assurance** – this will involve a range of activities, including training, accreditation of providers, internal and external audits, and plan to reinforcing referral chain.

**Distribution strategies** – particularly for vouchers, the decision about how to distribute is critical, including a choice of community-based agents and/or through retail outlets such as pharmacies.

**Detection and prevention of fraud** – fraud can occur at many different stages and therefore requires a range of preventive strategies. For example, for a voucher scheme, fraud can take the form of the creation of fake vouchers or collusion between distributors and clients during distribution, between clients and providers during use, and/or between providers and claims processing agents during payment of vouchers. Careful systems for validating claims (including use of text messaging to contact beneficiaries directly) and zero tolerance for fraud are two important strategies to contain fraud (Boler and Harris, 2010).

# **Conclusions and outstanding questions**

The paper shows the variety of DSF schemes in operation, and the variety of outcomes that they can produce, depending on their goals, design, context, funding and implementation. It is not easy to generalize about such wide-ranging policies, but it is clear that some can produce impressive results, in terms of increased utilization, if the preconditions outlined above are met.

There are however a number of outstanding questions which research to date has not adequately addressed. Most importantly, the relative cost effectiveness of DSF in relation to other strategies for achieving similar goals not been assessed. That paying people to use services increases service use is not in itself surprising – of more interest is whether it does so more effectively and at lower cost than alternatives (some of these issues are explored in Table 6). This comparative cost effectiveness analysis, allowing for different contextual features, is still outstanding, in addition to the other gaps highlighted in the synthesis - for example, a need for more focus on equity analysis, and analysis of DSF schemes’ impact on financial protection, quality of care, and health outcomes. Where increased utilization is measured, there is little understanding of its determinants. Despite the rapid increase in the popularity of DSF, rigorous evaluations of DSF remain rare in low and middle income countries.

# **Acknowledgements**

This article is based on a paper commissioned by the World Bank, East Asia Region. Many thanks go to Seemeen Saadat for her assistance with the literature search, and to the reviewers for their comments.

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|lcashforservices<br>i|||||
|---|---|---|---|---|
|<br>JananiSurakshaYojana, India, 2005 <br>- ongoing|<br> |In-facilitydelivery (also healthworkers<br>incentivizedtoensure 3 ante-natal carevisits;<br>attended orin-facilitydelivery; onepostnatal<br>— <br>check up; childimmunization; promoting<br>breastfeeding). Beforethat,therewasthe<br>National Maternity Benefit Scheme (NMBS}<br>(2001-5)for nutritionalsupport<br>forpregnant<br>women. Itgave a one-time cash paymentper<br>pregnancyofRs. 500 tobelow-poverty<br>line (BPL}<br>pregnant women, 19years ofage or<sup>older, for</sup><br>uptotwo pregnancies that resulted in live<br>births,|Households belowpoverty line, or ofscheduled(low) <br>cast ortribe +entire population in 10highfocus states<br> with lowest in-facility births: UttarPradesh,<br>Uttaranchal, Bihar, Jharkhand, Madhya Pradesh,<br>Chhattisgarh, Assam, Rajasthan, Orissa, andJammu and<br>Kashmir||For<sup>first</sup><br>two live births, after delivery in agovernment<br>Joraccredited private health facility, eligiblewomen<br><br>would receive 600Indian rupees (US$13-3) in urban<br>areasand700rupees (515-6) in rural areas.The cash<br>|incentive is higher inthe 10low in-facility birth states:<br>1000 rupees ($22-2) inurban areas and 1400rupees<br>($31-1) in rural areas.Also,500($11) rupeesforhome<br>delivery<br>for women belowpoverty line. In case ofCS,<br>thewoman receives1,500 rupees. ASHAs (accredited<br>social health activists) also paid 200rupees (54-4) in<br>urban areas and 600rupees ($13-3) in rural areas perin-<br>facility delivery assisted bythem in high-focus states.<br>No payments tofacility staff.There aresome variations<br>in implementation across states, however. Initially<br>the<br>scheme wasfocussed on the public sectorbutprivate<br>facilities beingincluded. Paid up to 1,500rupees per<br>delivery.||Lim et al. 2010; Dagur<br>jet al 2010;V Paul2010<br>|
|2\Safe DeliveryIncentive Program, [<br>Nepal, 2005-ongoing|In facilitydelivery .(Alsohas P4P elements and<br>since 2009free deliverycare has beenadded) —_|[Universal entitlement, butamountsvaryaccordingto<br> ecological zones(higher<br>formountains and hillsthan<br>lowland areas).Women inthe low-HDI districts<br>received free deliveries originally-this isnow<br>extendedto all. Originallyrestrictedtowomenwith —_<br>fewthantwo living children oran obstetric<br>complication (as diagnosed by the health provider) but <br>this restriction now lifted|Conditional cashtransfers,on delivery, inpublic<br>—_/facilities originallybutnowextendedtosome private<br>and private not-for-profitfacilities.500NRS ($7)paidto <br>women in plains districts; 1,000NRS ($14) in hill<br>|districts; 1,500NRS ($21) inmountain districts. Part of<br>wider Safe Motherhood Programme, with supply-side<br> jinvestments|Hanson&Powell-<br>Jackson 2010<br> |(Ensoret al 2009for<br>funding}|
|3)Conditional In-kind transfers,<br>Rwanda, 2010|in-kind benefits linkedtoANCinfirst4months<br>ofpregnancy, institutional delivery, andPNCin<br>first7days bymother-child pairs||Piloted in2010in 30sectors -oneperdistrictofthe | <br>|country||Oncompletion ofeach stage,themotherreceivesa<br>package includinga bar ofsoap, water purification<br>products, and a choice ofumbrella, adult clothing, ora<br>well-babypackage|/Ngabo &Humuza2010<br>(newsbrief)-<br>)www.rbfhealth.org|
|Vouchers|||||
|---|---|---|---|---|
|4|Chiranjeevi Yojana, Gujurat, India,<br>2005 onwards|One prenatal consultation, sonography,<br>transport, deliverycare, anycomplications.<br>Women receive Rs 200 fortransport. ANCand<br>PNCnotincluded|Below poverty linewomen in remote areas. Piloted in<br>five districts ofthe state. 10million pop, ofwhich43%<br>estimated BPL. BPLcard used asevidence of<br>entitlement. Expanded state-widefrom 2007.||The state contracted with private providersto provide<br>|delivery care cash-free for identifiedwomen.||Bhatet al.2006<br>& 2009;<br>Mavalankar, 2009|
|5/Output-based aidprogramme,<br>Kenya, 2005-8|Safe motherhood, family planning,gender<br>violence recovery.TheSMvoucherscovers4<br>ANC visits, a delivery visit, and postnatal care<br>(PNC) within 6weeks after delivery atany<br>contracted facility.The FPvoucher entitlesthe<br>userto anyofseveral moderncontraceptive —_ <br>methods: bilateral tubal ligation (BTL),<br>vasectomy, hormone-based implants, and<br>IUCDs, The GBV voucher entitles theuserto<br>medical examination, treatment, and|Poor households in 5 pilot sites (3 rural, two urban<br>—_|slums) in economically disadvantaged parts ofKenya.<br>Total population 3 million. Targeting toolsdeveloped<br>to identify suitable households. Rural districts of<br>|Kisumu, Kitui, and Kiambu, aswell asthe Nairobi<br> informal settlements ofViwandani and Korogacho.|Vouchers, sold at highly subsidized price. Cost$2per <br>|SMvoucherand $1.25 perFPvoucher. Redeemed at<br>—|publicand privatefacilities||Project site:<br>—_[http://www.output-<br>based-aid.net/e102/.<br>Bellows et al2009|
||ounseling||||
|6]Reproductive Health Vouchers,<br>Uganda:<br>STIvouchers beginning<br>2006 and SM vouchers beginning <br>2008|—_|STIVoucher coverstreatment<br>but not transport. <br>—|SMVouchercovers 3 ANC visits, safe delivery, 1<br>|PNC visit. ANC package includes malaria<br>prophylaxis, ironsupplements for anemia,HIV<br>screeningand services, andgeneral monitoring<br>ofthehealth ofmotherand fetus.||SM andSTIvoucher program beginning2008in22<br>|districts inwestern Uganda (4-5million population).<br>STIvouchers<br>for everyone, SMvouchers<br>for poor<br>|women.<br>STI patientsencouraged touse half the<br>|vouchers and sharethe otherhalf with theirsexual<br>partners. Marketed byradio initially|Vouchers, atsubsidized rates: Ush 3000 ($1.3)forSM —<br>voucherandsame price forpair ofvouchersforSTI.<br>— <br>Redeemedonly<br>at private facilities|[Bellows and Hamilton<br> |2009; Kilonzo et al.<br>2010; MarieStopes 2010|
|7|Vouchersforpoorpregnant<br>women,Cambodia,from 2007|3 antenatal care visits, deliveryand 2postnatal<br>carevisit, a5well astransportation costsfor5 —_<br>round trips between herhome andthe health<br>centre, andforreferralsfromthe health centre<br>tothereferralhospitalincaseofcomplications.|[Poor pregnant women inthe catchmentarea ofrural<br> [health centres inthree districts||Vouchersforprimarycare and access costs atpublic —<br>health centres, Referral costs covered byexisting<br>Health Equity Funds (HEF). Inthesame areas,<br>performance-based contractingand staffincentives ar<br>alsoinplacetoprovidesupply-sideincentives|{IrPoret al 2010<br>e|
|[vouchers<br>8/Maternal Health Voucher Scheme,<br>Bangladesh, 2007||3 antenatal carevisits, safe delivery, 1postnatal <br>visit, transport upto Taka 500 forfirst two<br>pregnancies||Poorpopulation<br>in 33 sub-districts covering10.7<br>million people (7% ofpopulation);<br>9 sub-districts<br>applied universallyand remaining24weretargeted at<br>poorwomen with first orsecond pregnancy. Identified<br>byFamilyWelfare Assistants,who distribute booklets|Vouchers. Beneficiary entitlement includes free<br>antenatal, deliveryand postnatal care, plusTk100per <br>|ANCvisit;Tk2000forsafe delivery; Tk 100 forPNCvisit<br>|Tk 100fortransport<br>for institutional delivery; alsofund<br>|for referral and gift box for baby.Supposed to receive<br>at time of service, but often have to collect later.<br>Providers also get incentive (half offunds paidto<br>facilities)|Olivier-Schmidt<br>et al.<br> |2010; Ahmed & Khan<br>; |2010; Koelmoos etal.<br> <br>|2008; Hattet al. 2010|
|---|---|---|---|---|
|3|Indonesia midwife vouchers,<br>Pemalang province, Java. 1998-<br>2004|Pre-paidvouchers(bookletof29) distributed<br>six services, includingdelivery, referral to<br>hospital ifneeded,<br>ANC, PNC, infant care, FP,<br>and family health care services|for|Poor pregnant women<br>in project villages.<br>Identificationdone by the projectmidwives|Funded byWorld Bank Safe Motherhood project, and<br>accompanying performance-based contracts for village<br>midwives (the aim was to encourage them to seekout<br>low incomewomen). Fixed amounts paid pervoucher.|/Tan etal. 2005<br>|
|10/Sehat<br>Voucher Scheme (pilot),<br>Pakistan, 2008-9 - administered<br>through the Greenstar<br>program/Goodlife service<br>providers|3 ANC visits,vaginaldelivery,<br>1 PNC visit,FP<br>—|counselling|2000pregnant women<br>in low income urban Dera Gazi<br>Khan district:womenwho have previously delivered at<br>home, monthly income ofUSS42.68on average, and<br>have neversaved money for delivery(indicating lackof<br>information about the importance of ANC visits and —_—<br>institutional delivery).|[Vouchers at highly subsized rates (pay Rs. 100orUS$_<br>|1.21 for US$ 50worth ofvouchers); covers transport as<br>_|well as services.Transportcomponent (covering all<br>|services) isworth around $6,Haveto access Greenstar<br> services. Also has componentofincentive payments<br>for providers|—|Bashiretal. 2009|
|11/STI Vouchers, Nicaragua, 1995<br>onwards|FreeSTI testing andtreatment, including: a<br>medical consultation; screening testsfor<br>syphilis, andtrichomoniasis, candidiasis,<br>gardenerella & cervical cancer (Papanicolaou<br>smear) inthe case offemale redeemers;<br>diagnosis of other STIsthrough physical<br>examination; health education; provision of<br>information booklet, especially designed forsex<br>workers, and 24condoms duringeach visit.<br>Presumptivetreatment with a single-doseof1<br>gram of azithromycin is<br>offered.|2,000vouchers distributedto HIV vulnerable<br>populations in Managua (sexworkers, and latertheir<br>partners and client, transvestites and adolescent glue- <br>_|sniffers). Distributed though NGO in 5-6main<br>prostitution centres of city<br>|Vouchers distributed every 6months; expire after 2.5<br>|months; iftest positive for STI or are pregnant,given<br> }voucher<br>to return foradditional consultation. Services<br>at ten contracted centres, which are assessed for<br>quality before and during implementation. Initially<br>public, private and PNFP, butpubliccentres later<br>dropped||Sandiford et al 2002;<br>|Borghi et al 2005|
|12/5RHVouchers, Nicaragua, 2000|SRH: 1consultationand 1 follow-upvisit for<br>advice/counselling, contraception,treatment of<br>STIs orreproductive tract infections (RTIs),<br>pregnancytestingand/orantenatalcare|Adolescent males andfemales in disadvantaged areas<br>|ofManagua (ages 12-20)||Vouchers; transferable;validfor 3months. Providers<br>included public, private and PNFP. Providersgiven<br>training,treatment protocols and financial incentives.||Meuwissen et al.<br>2006a/'2006b/2006c/200<br>|6d/2006e|
|[Cashlinkedto|pecificserviceuse|||
|---|---|---|---|
|<br>1)JSY, India|<br>In-facility births have increased atthe national level. Slight<br>increase in ante-natal care and shiftfrom home based<br>attended delivery<br>to in-facility delivery. Of the LOlow in-<br>facility birth states, same had low uptake such as Bihar<br>(15%) and UttarPradesh (7%), while others suchas Orissa<br>and Madhya Pradesh had high uptake (42% and 44%).<br>District level variations are significant:from under5% in<br>141 districts to more than or equal to 30% in 128 districts.||Receipt offinancial assistancefrom JSYwas generally<br>higher inthe middle bands ofwealth in highfocus (lowin<br>|facility birth) states and inthosewith middle levels of<br>education -the poorestand least educated did not<br>|necessarily benefitthe most as perprogram objectives. The<br>highest rates ofJSY paymentswere towomen living in rural<br>areas, but close to a health facility. Except inthe northeast<br>|states,womenfrom the socially disadvantaged casteswere<br>significantlymore likely thanwerethe other groups to<br>receive JSY payments|Hot assessed, howeverthere is evidence that<br>[not all eligiblewomen received payments.<br>An assessment of<sup>five high-focus states in</sup><br>India indicated that 7-33% ofwomenwho<br>|delivered in facilities reported not receiving<br> |anymoney after delivery|
|2/SDIP, Nepal<br>|Women in the treatedgroup were 4.3 percentage points<br>(26 percent) more likelyto deliver in a publichealth<br>facility,4.2 percentage points (17percent) more likelyto — <br>deliver with a skilled birth attendantand 1.2percentage<br>points (36 percent) more likelytohave a caesarean section.<br>The impact varies dependingonthe size ofthe financial<br>package relative tothe cost of care and the quality of care<br>provided in hospitals and primary health care centres.<br>|The richer households benefited more as had higher<br>utilisation rates. Poorer women<br>also less likelytobe<br> |informed. However, interms ofincreased likelihood of<br>having a supervised delivery, the main impact was onthe<br> |middle quintile (66% more likely ifexposedtotheSDIP)<br>andthe lower two quintiles (64% more likely ifexposed to<br>|the SDIP)<br>|20% offacility costs covered on average, so<br>households are noteffectivelyprotected.<br>Out-of-pocketpayments for institutional<br>|delivery care disrupt living standards and<br>force some households into poverty. 12.8<br>|percentofhouseholds incurred expenditures<br>for delivery care that exceeded 10percent of<br>total consumption (the standard threshold<br>for catastrophicexpenditure). Out-of-pocket<br>payments also pushed an additional 1.9<br>percent ofhouseholds into extreme poverty,<br>equivalent<br>to a 25 percentincrease in<br>poverty.<br>|
|vouchers||||
|<br>3|Chiranjeevi<br>Yojana,<br>Gujurat, India,<br>2005 onwards|<br>In firstyear, institutional deliveries inthe five districts<br>increasedfram 38per cent to59 percent.4.7% of<br>|deliveries in thegroupwere caesareans. A later report<br>=<br>|statesthatpublic sectorinsitutional deliveries have been<br>= <br>declining|<br>A household-level survey of beneficiaries (n=262) and non- <br>users (n=394) indicated that the scheme iswell-targeted to<br>the poor (only 6% of beneficiaries were non-poor) but<br> |manypoorpeople do not use the services.|<br> |The beneficiaries saved more than Rs 3,000<br>|(USS$75) in delivery-related expenses and<br>were generally satisfied with the scheme,<br>although5% reported notreceiving transport<br>funds and4% reported being askedfor<br>moneyby staff.An average of Rs 654was<br>spend per person on additional medicines.|
|4/OBA, Kenya|Significant increase in uptake of safe motherhood services; <br>limited increase in the uptake ofFP services (possibly<br>driven by socio-cultural/other<br>factors)||Where abilityto pay is low, Marie Stopes pays forthe<br>vouchers. In rural areas,95% ofvouchers purchased by MSK<br>(the service provider)|Households benefitfrom high subsidies (e.g.<br>|200 KES for delivery package, compared to<br>600-1,500KES fordelivery in public sector<br>(plusadditionalcostsfordrugs,ANC,PNC)|
|5/RHVouchers,<br>Uganda|[Utilization ofSTItreatment services increased by15% (not<br>significant) during 2006-2008 (the firstSTI program period).<br>More than40% of redeemers men. Significant increase<br>(48%) in use of STI services for those living within 10km of<br>facility||ForSTIs, nottargeted atthe poor -available<br>to all. No equit<br>|analysis of uptake|y}80% savings offered on normal service costs<br>forSTI|
|---|---|---|---|
|6/Vouchers for<br>poorpregnant<br>women,<br>Cambodia,<br>2007||Facilitydeliveries increased overall from 16.3% in 2006to<br>|24.9% in 2007. This includesvoucher and HEF recipients, as<br>well as self-paid deliveries. Forvoucher recipients,<br>utilization of facilities increasedfram 2.4% in 2006 to 7% in<br>2008. However,there is a large differencebetween<br>vouchers distributed andvouchers utilized. Highest<br>utilization ofvoucherswasfor initial ANC visits: of the<br>1,093 poor pregnant women who receivedvouchers in<br>2007,855 (78.2%) used theirvouchers forANC1, 665 (60.8%)<br>forANC2, 501(45.8%) forANC3 and 487 (44.6%) for|{No analysis, butauthors mentiontargetingproblems.|No information|
|7|Maternal<br>HealthVouche<br>Scheme,<br>Bangladesh,<br>2007|Institutional delivery increased 2.5timesfasterthan other<br>r |areas in DSF areas, especially after Jan 2008 (corresponding <br>to an increase invoucher uptake). 92% of pregnant women<br>invoucherareas had atleastoneANCvisitcompared to<br>76% in control areas;58% deliveredwith qualified provider <br>compared to 27% controls;44% facility delivery compared<br>to19% controls;31% PNCvisitcomparedto 20% controls. — <br>In multivariate analysis,<br>awoman living in a universal area<br>has a probability ofdelivering ina health facility that is 26.2<br>percentage points higherthanthat byawoman livingina<br>non-DSF area.The correspondingdifferencefor the means- <br>tested area is 12.9 percentage points. No difference for<br>caesareans|[Poorerwomen in the universal areaswere somewhatmore <br> |likelytoreceive a voucher than the richest women.<br>|However, the differences betweenthe quintiles are not<br>significant. Inthe means-tested site, as intended,<br> |significantlymorewomen inthe bottomthree quintiles<br>|(78%) received vouchers than didwomen inthe richest<br> |quintile (49%). Still,thefactthat nearlyhalfofthewomen<br>jinthe richest quintile obtained avoucher inthe means-<br>|tested area raises a question about the effectiveness of<br>|poverty-related targeting. In control areas,womenfrom<br> |thetop80% of thewealth distributionwere morethan 3<br>times more likelyto deliverwith a qualified provider than<br>womenfrom the poorest20%. In universal areas, this ratio<br>was 1.18, while in means-tested areas the ratiowas 0.91.||Only 60-65% ofwomen reporting receiving<br>cash fornutritionalfood and lessfor<br>—|transport incentives. Out-of-pocket<br>expenditures on deliverywere significantly<br>lowerin universalvoucher districts (945Taka)<br>and among means-tested voucher users (896)<br>|compared to controls (1480), however|
|8|Indonesia<br>midwife<br>vouchers,<br>Pemalang<br>province, Java.<br>1998-2004|Utilisation ofmidwife services increased, though<br>attribution is hard asthevoucherscheme coincidedwith — <br>contracting ofmidwives and otherchanges.Women<br>reported more confidence inthe midwife services|Poor women were using midwife services at the end of the<br> |project, compared to start where few did. No assessment<br>ofaccuracy ofvouchertargetingmadehowever||Notassessed|
|9|Sehat Voucher <br>Scheme (pilot), <br>Pakistan, 2008||Over<br>a period of12 manths: 1,999voucherbooklets<br> |distributed; 20% increase inANCvisits; 68% delivered at<br>|Good life facility; 79% utilized FP counselling; women<br>beneficiaries also brought 3-4pregnantwomen to health<br>facilities for carefram theirfamilies orneighborhood.|Not assessed|Notassessed|
|---|---|---|---|
|10}STI Vouchers,<br>Nicaragua, 1995<br>onwards||Since 1995, over 15,000vouchers distributed, over 6,000<br> |consultations provided, and numerous cases ofSTI treated, <br>with more than40% redemption rateforvouchers.<br>Successful in reaching high-risk groups, providing high<br>quality service and treating92% ofthe fourmastfrequent<br>STls ws. only15% in the absence ofvouchers.|Redemption ofvouchers higheramongst poorest and<br> |amongstthose with highest initial rates ofSTI|The average cost per consultation in the<br>absence ofvouchers was estimated at USS12;<br>the cost perSTI cured atUS$200. Thetotal<br>direct cost(includingtransport, snacks and<br>limited medical expenses) tovoucher<br>redeemerswas US54.46 (SD 5.3). Opportunity<br>cost oftimewas USS 2.64|
|11)SRH Vouchers, <br>Nicaragua, 2000<br>||3,067 girls redeemed 3301vouchers,with 6% usingmore<br>|than 1voucher. 40% came backfor further consultation.<br>34% ofvoucherswere used for contraceptives, 31% for<br>complaints related to an STI or RTI, 28% for<br>advice/counselling, 28%for antenatal check-ups, 18%for<br>pregnancytesting. In 10% ofthe consultations, vouchers<br>were used onlyfor advice/counselling. 20% redemption<br>rate bygirls - Voucher receivers had a significantly higher<br>use of SRHC compared with nonreceivers, 34% v. 19%; At<br>schools, sexually activevoucher receivers had a<br>significantly higheruse ofmodern contraceptives than<br>nonreceivers,48% versus 33%; also highercondam use<br>during last sexual contactamong receivers vs. non-<br>receivers in neighborhoods<br>|Not assessed<br>|Notassessed<br>|
|Juongterm cash||||
|<br>12/Family<br>Allowance<br>Program<br>(PRAF]'s BMI<br>Voucher,<br>|In trial, antenatal care increased by 18%; well-child<br>visits/preventative care by20%|BMI reached84% of its target group, accordingto<br>evaluation offirst phase, but40% of beneficiaries intop<br>two quintiles|Notassessed; however overall transfers<br>estimated at4% of average household<br>consumption|
|Honduras, 1990||||
|13|Opportunidade <br>s, Mexico, 1997||No<sup>increase in ANC</sup><br>in rural areas. 6.12% point increase<br> |from base of 56% in urban areas (second phase). Small but<br>significant increase in use ofmodern contraceptives by<br>treatmentgroup vs. contral; no difference in birth spacing;<br>Beneficiaries received 12.2% additional prenatal<br>procedures. Howeverno difference in likelihoodoffacility<br>delive|Lowleakage<br>- 80% ofbenefitsgoto40% poorest families<br>|(although later studiesfound reduction - 60% of<br>beneficiaries in bottomtwo quintiles).8% poverty<br>|reduction in intervention areas||Notassessed; however overall transfers<br>estimated at20% ofaverage household<br>consumption|
|[Cash|linkedtospecifi|cserviceuse|
|---|---|---|
|1)JS¥, India|Deliveries may be done by unskilled support staffvs. skilled<br>nurses or doctors. Best practices, such as partogram, neonatal<br>resuscitation, and kangaroo care, are notfollowed. The system<br>of referral to a higher level for emergencies is inadequate.<br>Most mothers and babies are discharged within hours after<br>delivery because the hospitals lack amenities, and families<br>wantto return home having got the cash incentive. As a result,<br>there is inadequate time for mewborn-care counselling,<br>stabilisation of the post-partum mother, and detection of<br>danger signs in the mother and the infant.|Unable to detect a signifcant impact ofIS¥ on<br>[maternal mortality.<br>Difference-in-difference<br>|analysis does not show significant effect on<br>perinatal and neéo-natal mortality. However,<br>JSY payment was associated with a reduction<br>of aboutfour perinatal deaths per 1,000<br>|pregnancies in the matching and with-versus-<br>without analyses, and a reduction of about<br>two neonatal deaths per 1,000 livebirths.|
|2/SDIP, Nepal<br>|No assessment made of impact on quality of care, but the<br>limits to service provision (after as before) are highlighted,<br>particularly at lower level facilities. (Shortages of staff and<br>equpment limitthe services, especiallyfor emergency<br>obstetric care.)<br>|Not assessed, but limited impact expected<br>given limited increase in emergency obstetric<br>care and quality of care constraints<br>|
|vouchers|f|f|
|3|Chiranjeevi Yojana,<br>Gujurat, India, 2005<br>onwards|Not assessed, but authors note that PNC is notincluded inthe<br>package||Not assessed|
|4)Safe Motherhood<br>Vouchers, Kenya,|Not assessed|Not assessed|
|5/RH Vouchers, Uganda||The proportion of diagnoses correctly treated ranged from 79% <br>for balanitis to98% forgonorrea.||Knowledge ofSTI symptoms increased 18<br>percent between the first and second years<br>(adjusted odds ratio, aOR=1.43; 95 percent<br>Cl=1.22-1.68). The prevalence of syphilis, as<br>measured bythe VDRLtest, decreased 42<br>percent between the two surveys<br>(aOR=0.63795 percent Cl=0.48-0.79). There was<br>a greater reduction in the prevalence of<br>syphilis among respondents who lived within<br>10 kilometers of a contracted facility (57%<br>decreaseversus20%forthosefurtheraway)|
|6/Vouchers for poor<br>pregnantwomen,<br>Cambodia , 2007|Not assessed|Not assessed|
|---|---|---|
|7| Maternal Health<br>Voucher Scheme,<br>Bangladesh, 2007|General satisfaction with services by beneficiaries. However,<br>provider quality standards not always enforced. Also users not<br>well informed about scheme. Choice of providers was limited.<br>Also, the voucher only applies to the area of residence while it <br>is expected that<br>awoman will goto stay with her parents for<br>deliverywhich may be in a different (non-voucher) area. Delay<br>in releasing funds to reimburse vouchers and service providers<br>created problems in the initial stages of the program.<br>Providers report being over-burdened because of increase in<br>demand. Inadequate service providers and facilities to address<br>increased demand forANC services; shortage of<br>obs/Gynaecologists and anesthesiologists at facilities;<br>variation in training on DSF across regions||The incidence of complicated deliveries,<br>|stillbirths, and newborn deaths was lower in<br>|voucher UHCs than in control UHCs, likely a<br> |consequence of more maternal care in<br>|voucher UHCs.|
|8/Indonesia midwite<br>vouchers, Pemalang<br>province, Java. 1998-<br>200-4|Not assessed|MMR declining in province overthe period but<br>cannot be attributed to project|
|9)Sehat Voucher<br>Scheme (pilot),<br>Pakistan, 2008|Not assessed|Not assessed|
|10|STI Vouchers,<br>Nicaragua, 1995<br>onwards|Not assessed|Reduction in prevalence ofgonorrhea in the<br>female sex worker population by an average<br>of5.25% per year; reduction in incidence in<br>repeat users by 11.5% peryear; reduced<br>prevalence of syphilis by an average 10.25%<br>per year;women remained STI free longer;<br>and while HIV prevalence has increased in<br>Managua, it is much lower compared to that of<br>sexworkersinothermajorcities|
|11|SRH Vouchers,<br>Nicaragua, 2000|User satisfaction higher among voucher receivers vs. non-<br>recievers, especially amonggirls not yet pregnant (91% v.85%); <br>88%voucher receivers satisfied with care at reception vs.80%<br>for non-receivers; no statistically significant difference in<br>perception about doctors’ explanation (83% ws.80% Tor<br>receivers v. non-receivers). Priorto voucher implementation,<br>half the simulated patients (SP) leftthe doctors’ office without<br>contraception; reported decision on contraception beingmade<br>by doctor; with voucher, higher rate of contraception<br>distributed, also respondents more frequent mutual decision<br>makingon contraception. However, SPs with vouchers stated<br>that their wait timeswere longer in some cases, and there may<br>have been somegaming ofthe system by providers. Also,<br>some quality indicators improved during intervention but<br>dropped once itwas stopped|Voucherreceivers had significantly higher<br> |levels ofknowledge aboutmodern<br>|contraceptives (OR 1.3), STIs (OR 2.6) and the<br>ways to preventSTIs (OR 1.2).|
|---|---|---|
|jongt|ermesh—[CSSCO|OOOCSCSC*d|
|12|Family Allowance<br>Program (PRAF)'s BMI <br>Voucher, Honduras,<br>1990 onwards|Poorindividual counselling on nutrition reported, as well as<br> |gaps in information to beneficiaries|Evaluation offirstphasefound no evidence of<br>health or nutritional gains, perhaps because of<br>low level of payments|
|13|Opportunidades,<br>Mexico, 1997|Oportunidades beneficiaries received 12.2% more prenatal<br>procedures compared with non-beneficiaries (adjusted mean<br>78.9,95% Confidence Interval (Cl): 77.5-80.3; P<0.001). Higher<br>perceived quality of care among users - which may be result of <br>greater sense ofempowerment achieved through the overall<br>program.Some small-scale studies suggesthoweverthat<br>publicfacilities were not always able to cope with the increase <br>in demand (e.g. running out of drugs)|Oportunidades beneficiary statuswas<br>|associated with 127.3 g higher birthweight<br>|among participatingwomen anda 4.6<br> |percentage point reduction in low<br>|birthweight. Also lower incidence of illness<br>amongst beneficiary children, reduced<br> |stunting and increased growth. Maternal and<br>child mortality delined in programme areas,<br>but this is based on administrative data alone<br>anduncontrolled|
|Cashlinkedtos|ecificserviceuse||||||
|---|---|---|---|---|---|
|1)JS¥ India|<br>Budget allocation of 15-4<br>billion rupees ($342<br>million) inthe 2009-10<br>‘| <br>financial yearto reach 9.5<br>million women<br>(estimated 36%oftotal<br>births in India forthe<br>year)||7% offunds at state level can be used<br>foradmin; 1% at districtand 3% at<br>facility||Not assessed|Financed by central<br>governmentthrough taxation|Low middle<br>|income|
|2/SDIP Nepal|Five year estimated cost<br>of NRs. 0.95 to 1.3 billion<br>(GBP 7.3-9.9 million)||Not assessed|Not assessed|Grant funding from theWorld<br>Bank, DFID and AusAID<br>funding; long-term fundingto<br>be absorbed bygovernment||Low income|
|vouchers||||||
|<br>3)Chiranjeevi<br>Yojana,<br>Gujurat, India,<br>2005 onwards|<br>No information|<br>Average cost of Rs 1,795 (S45)<br>negotiatedwith providers, tocover<br>all costs, and across all deliverytypes|<br>Notcalculated, but<br>= <br>|authors notethatby<br>|contracting in bulk<br>with private<br>providers, the<br>government is<br>petting a better price<br>- 545 per delivery,<br>compared to the<br>average paid bynon-<br>covered people of<br>$100|<br> |No information|<br>Low middle<br>income|
|A/OBA, Kenya|Expenditures Phase I-<br>June 2006<br>to Oct 2008: 6.1 <br>million Euros|21% on management and<br> |administration; 79% on direct service<br>costs. Provider reimbursements for<br>vouchers: C-section/complications in<br>delivery USS 292; normal delivery $70;<br>ANC $14; surgical contraception $42;<br>implant $28; IUCD $14. More cost<br>effective forgovernment facilities<br>than NGO clinics. NGO clinics have<br>added costs such as for space rental<br>which government facilities do not<br>|Not assessed|Funded mainly through the<br>KiWand Marie Stopes Inil<br>through 2012, butthe<br>Government ofKenya (Gok)<br>has contributed. After 2012,<br>financingwill rely on the Gok<br>and other partner buy-in|Low income|
|---|---|---|---|---|---|
|||have to bear||||
|5/RH Vouchers,<br>Uganda||US$ 6.3 million (for 3<br>years beginning 2008)|Provider reimbursements for<br>vouchers: normal delivery 558;<br>complications $140; STI treatment<br>$10; $0.11 pervoucher sale. Average<br>total cost of US$53 per person forSTI<br>voucher. Patient care only absorbed<br>18% ofprogramme costs in firsttwo<br>years (21%went on management and<br>rest of marketing, TA etc.). However,<br>unit costs dropped to $21 per client<br>visit in 2009,|Not assessed|STI vouchers 2006-8funded by <br>KiW. Beginning October 2008,<br>both components funded for 3<br>years through KfW and World<br>Bank(GPOBA) partnership||Low income|
|6|/Vouchers for<br>poorpregnant<br>women,<br>Cambodia,<br>2007|No information|Unit cost: Approx. USS 7.5 for a normal] <br>delivery and USS.0.25 foreach<br>antenatal and postnatal carevisit+ a<br>variabletransport cost estimated at<br>USS 0.1 perkm.|Not assessed|Assistance from Belgian<br>Technical Cooperation|Low income|
|7|Maternal<br>Health Voucher<br>Scheme,<br>Bangladesh,<br>2007|No information<br>|Providers compensatedforvouchers<br>depending on service provided as<br>follows: 10 Tkforvoucher<br>distribution; 70 Tk forblood and urine<br>tests; 150 per ANCvisit; 300 Tknormal<br>delivery; upto 6000 Tk for c-section;<br>1000<br>Tk foreclampsia/vaccuum;50Tk<br>forPNCvisit;100Tkformedicine.||Notassessed|Donor funding administered<br>= <br>byWorld Bank currently||Low income|
|8lIndonesia<br>midwite<br>vouchers,<br>Pemalang<br>province, Java.<br>1998-2004|The total cost of base<br>wages and voucher<br>reimbursementsforthe<br>20 TPC midwives in<br>|Pemalang district was<br>over Rp. 1.2 billion<br>(US$134,000) forthe<br>period 1999 to 2004; in<br>addition, two stafffram<br>the District Health Bureau<br>were each paid a monthly<br>salary of Rp. 150,000for<br>their role in monitoring.<br>The District Project<br>Monitoring Unit (DPMU}<br>also received an<br>unknown income for its|In 1999, the voucher payments were<br>Rp. 60,000for delivery, Rp. 30,000 for<br>|family planning, and Rp. 5,000each<br>for other services||Not assessed|Project costs were paid by the<br>World Bank and the central<br>governmentthrough 2003;<br>2001 costs for base wages<br>were paid bythe districtwhile<br>vouchers continued to be<br>reimbursed bythe central<br>government with World Bank<br>funding.||Low middle<br>income<br>|
|---|---|---|---|---|---|
|9/SehatVoucher<br>Scheme (pilot),<br>Pakistan, 2008||No information|Rs. 4000 perwoman (includes<br>provider and beneficiary entitlement)|Not assessed|Pakistan Initiative for Mothers<br>and Newborns (PAIMAN)<br>project funded viaJSI/USAID;<br>Expanded to another district,<br>with support from another<br>donor and local government.||Low income|
|10/STI Vouchers,<br>Nicaragua, 1995<br>onwards||USS 60,000 per year|Under thevoucher scheme,the<br>average cost per consultation<br>(voucherredeemed)was USS41and = <br>the average cost perSTI cured was<br>USS118. Direct medical costs including <br>administration accounted for 63% of<br>total cost; remaining on training and<br>supervision; distribution and other<br>support activities.|Voucherprogramme <br>had higher per STI<br> |patienttreated casts,<br>but lower per patient<br> |STI effectively cured<br>|costs at $118<br>|compared to status<br>quo of $200. Able to<br>negotiate good rates<br>with providers, who<br>appreciate steady<br>income from the<br>scheme||Donor funding; implemented<br>by ICAS<br>||Low middle<br>income|
|11/5RHVouchers,<br>Nicaragua, 2000||No information|Avg. unitcostperconsultation was<br>negotiated at US$ 4.56|Notassessed|IACS (Central American Health <br>Institute) administered; donor<br>funding||Low middle<br>|income|
|---|---|---|---|---|---|
|ltongtermeash||||||
|12|Family<br>Allowance<br>Program<br>(PRAF)'s BMI<br>Voucher,<br>Honduras, 1990<br>onwards|USS 3.5mn per year (19<br>2005)|904 No information|Notassessed|Being funded mainly through<br>IADBwith somefundingfrom<br>Government ofHonduras||Low middle<br>jincome|
|13] Opportunidade<br>5, Mexico, 1997||$3.6 billion in 2007|30% of costs spent on targeting,<br>accordingtoone study|Notassessed|Funded via 1bn loanfrom<br>IADB - Oportunidades also has <br>won a significantcommitment<br>from the government<br>representing46.5% of<br>Mexico’s federal annual anti-<br>poverty budget (Also recently<br>approved 1.25bn funding via<br>WEfor2011-13)|Uppermiddle<br> jincome|
**Table 5 Typical strengths and risks associated with the three main DSF approaches**

|Mechanism|Summary of strengths|Summary of risks or challenges|
|---|---|---|
|Cash<br>for|Simpler version – can be implemented|Higher risk of weak management and|
|services|through integrated services and at large<br>scale, if desired|patchy implementation, especially if no<br>third party administrator|
||More suited to categorical targeting (e.g. all<br>pregnant women) than individualized|Categorical targeting is always at risk of<br>‘capture’ by less poor groups|
|||Higher<br>risk<br>of<br>ignoring<br>supply-side<br>constraints, including low quality of care|
|Vouchers|Well adapted to community targeting and<br>identification of specific target groups|Costs of identification and distribution<br>tend to be high, especially when the<br>target population is dispersed|
||Marketing and distribution strategies can be<br>used to raise awareness of neglected or<br>stigmatized services (e.g. STI treatment).<br>Leakage also less likely for these services|Higher<br>risk<br>of<br>fraud<br>(e.g.<br>counterfeiting,<br>black<br>market<br>sales) than cash for services|
||Vouchers require third party administration<br>which, while costly, can be more effective at<br>ensuring quality of services provided|Few vouchers schemes are operated at<br>large scale|
||Allows, in principle, for easy tracking of<br>outputs||
|Long term<br>cash|Can address broader objective of providing<br>income support, while also promoting merit<br>goods and services with externalities|May work better as income support than<br>as a way of stimulating increased use of<br>priority reproductive health services|
||Payment mechanisms can be more direct|Despite<br>well-publicized<br>success<br>of|
||and cost-effective, e.g. into client bank|Opportunidades, not all schemes have|

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|accounts|achieved high accuracy of targeting or<br>significant changes to behavior|
|---|---|
|Tend to operate at scale and long-term,<br>which reduces the relative size of targeting<br>costs|As a social protection measure, the<br>overall cost is likely be high, making this<br>most sustainable in upper middle income<br>countries and above|

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**Table 6. Some outstanding research questions on DSF**

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# **DSF versus user fee removal**

**<mark>DSF schemes generally cover some part or all of service and access costs. From a consumer perspective, therefore, they can operate in a similar manner to the removal of user fees for specific services (e.g. family planning or delivery care). The main differences are that most schemes are targeted to certain income groups or areas, and some are managed by a third party structures. These third party structures may also leverage quality improvements, although again this can potentially be paralleled in an integrated structure, assuming payments to facilities are sufficient to allow some</mark> investment in quality enhancements.**

**<mark>Whether the higher costs of establishing and managing these structures is offset by greater targeting precision or more efficient purchasing will depend in the first case largely on demand conditions and the degree of public sector management capacity. If utilization of a service is low in absolute terms across all quintiles, then the costs of targeting are unlikely to be justified. Even if wealthier women are considerably more likely to deliver in a facility than poorer ones, if the overall skilled delivery rates are low, then targeting of payments may not be appropriate. There is also an important demonstration effect to consider – when wealthier women shift to facility deliveries, this will usually</mark> be emulated over time by other socio-economic groups.**

**<mark>On the supply side, administrative capacity is needed for good implementation of any of these policies. Effective financial management is highlighted as a challenge in most study reports, but</mark> particularly those utilizing regular government systems.**

# **DSF versus insurance**

**The cost-effectiveness and preconditions for DSF should also be compared with insurance approaches, which can have very similar goals – increasing service uptake and reducing financial barriers – although they commonly have wider financial protection aims as well. Some countries such as Argentina have adopted an insurance approach instead of CCTs: the Plan Nacer, for example, offers coverage for a package of basic interventions to all uninsured pregnant women and children under six. Its estimated cost is $10 per capita per month (World Bank, RBF 2010).**

# **The value-added of conditionality**

**<mark>While the Latin American CCTs such as PROGRESA have had positive impact on nutrition, health and development outcomes, the debate about the value-added of the conditionality continues, with unconditional cash transfers in other regions achieving significant gains for nutritional status of</mark>**

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**<mark>children, for example (Glassman et al. 2007). Conditioning comes with a cost, both in terms of monitoring but also for households. For example, an average household at the start of Progresa faced</mark> 32 conditioned visits for health care and talks a year; these carry clear opportunity costs.**

**<mark>Unconditional cash transfers give poor families most flexibility. Yet vouchers and conditions reassure governments and donors that money will be spent on desired goals. In practice, compliance with</mark> conditions is not always enforced rigorously (Chapman 2006).**

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**The costs and benefits of poverty targeting, and alternative approaches**

**<mark>Targeted schemes typically impose higher costs while potentially providing a more pro-poor result, but assessing both is a pragmatic issue, depending on the modalities adopted. In general, if DSF schemes do not target the poorest, they are likely to disproportionally benefit wealthier groups, whose utili</mark>** <mark>zation of health services is typically higher.  On the other hand, individual poverty targeting often leads to under-coverage of target groups and is costly. Whether these outcomes are acceptable depends on social goals – increased utilization across all social groups may be a priority, or there may be particularly disadvantaged pockets of population which are the priority.  Longer term political support for a program may also be increased if benefits are spread beyond the poorest.</mark> **<mark>Decisions on whether to target individually will depend on a large number of questions, including consideration of stigmati</mark>** <mark>zation, the availability of data for targeting, minimizing opportunities for patronage etc.</mark>

**<mark>In the Uganda voucher scheme, the high cost of conducting individuali</mark>** <mark>zed poverty assessment led to a decision to offer vouchers to all households in areas with high poverty</mark><sup>4</sup> <mark>. By restricting the areas to subcounties, leakage was thought to be minimized. The effectiveness of area targeting will depend on area characteristics, though, such as homogeneity of socio-economic characteristics. Densely populated and</mark> relatively homogenous areas such as urban slums may be particularly suited to geographic targeting.

# **Paying for demand and/or paying for supply**

**There is a shared logic to the impetus for DSF and provider pay-for-performance approaches. While demand has to be stimulated for certain services and their affordability increased, so too health workers incentives have to be ‘aligned’ and their motivation (via pay) increased. For this reason, many DSF schemes include a provider incentive component. Some design questions are also shared – what is the right level of incentive, which services should be prioritized, which group of consumers/providers to reward, and how to monitor? However, the risks are somewhat different. The main risks for DSF payments are that funds are wasted making payments to households who would have used services in any case, and that demand is generated for services which are of low quality (and consequent health benefits are not realized). High transaction costs of targeting and scheme management are also a source of inefficiency. For provider payment schemes, there are additional concerns about perverse effects, including gaming of the payments system, neglect of non-funded activities and the potential demotivation (for individuals, teams and cadres not included in the payfor-performance systems).**

**While both pay-for-performance and DSF have shown their potential to raise provision and consumption of services in the short-term, the longer term question is what happens when payments are withdrawn. Will changed behaviour be maintained? What are the benchmarks for assessing when**

> 4 Defined in this instance as ‘the poorest sub-counties where poverty incidence is above 50% and poverty density is above 100 people per square km’ (Boler and Harris, 2010).

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