The Impact of Vouchers on the Use and Quality of Health Goods and Services in Developing Countries: A Systematic Review
Background: One approach to delivering health assistance to developing countries is the use of health voucher programmes, where vouchers are distributed to a targeted population for free or subsidised health goods/services. Theoretically, vouchers are expected to successfully target specific populations, increase utilisation, improve quality, enhance efficiency, and ultimately improve the health of populations.
Objectives: The primary objective of this systematic review is to assess whether voucher programmes thus far have been successful in achieving these desired outcomes.
Methods: Using explicit inclusion/exclusion criteria, a search of bibliographic databases, key journals, and organisational websites were conducted in September - October 2010. Other search strategies used include bibliographic back-referencing, supplemental keyword searches using specific programme information, and contacting key experts in the field. A narrative synthesis approach was taken to qualitatively summarise the identified quantitative outcome variables in five categories (targeting, utilisation, efficiency, quality, and health impact). Using the direction of effect of outcome variables and the confidence in the study findings, the findings for each category of outcomes were aggregated and assigned to one of five pre-established conclusion categories: (1) insufficient evidence; (2) evidence of no effect; (3) conflicting evidence; (4) modest evidence of effect; or (5) robust evidence of effect. Sub-group and sensitivity analyses were also performed. A quantitative meta-analysis was not conducted due to the heterogeneous natures of the outcome variables reviewed.
Results: A total of 24 studies evaluating 16 different health voucher programmes were identified in this review. The findings from 64 outcome variables informed five main conclusions: (1) there is modest evidence that voucher programmes effectively target voucher for health goods/services to specific populations (based on four programmes); (2) there is insufficient evidence to determine whether voucher programmes deliver health goods/services more efficiently than competing health financing strategies (based on one programme); (3) there is robust evidence that voucher programmes increase utilisation of health goods/services (based on 13 programmes); (4) there is modest evidence that voucher programmes improve the quality of health services (based on three programmes); and (5) the evidence indicates that voucher programmes do not have an impact on the health of populations (based on six programmes); however, this last conclusion was found to be unstable in a sensitivity analysis.
Conclusions: The evidence indicates that health voucher programmes have been successful in increasing utilisation of health goods/services, targeting specific populations, and improving the quality of services. While these results are encouraging, the subsequent link that voucher programmes improve the health of the population is not evident in the data analysed in this review. The methodology used in this analysis allows policy-makers to synthesise evidence from heterogeneous studies and therefore include more data than could be used in a standard meta-analysis. However, vouchers are still relatively new and the number of published studies evaluating vouchers is a limitation. Future reviews using this methodology can compare health voucher programmes to competing financing techniques and incorporate new evidence on voucher programmes for evaluations currently underway; however, the synthesis tools used in this review should be validated.
EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK, ISBN: 978-1-907345-10-4, 81 pp.