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.
The Impact of Vouchers on the Use and Quality of Health Goods and Services in Developing Countries: A Systematic Review