Two common interventions, vouchers and conditional cash transfers (CCTs), make payments directly to individuals or households to empower them to use services. These interventions typically target vulnerable, poor, and underserved populations.
Vouchers are paper or electronic tickets that entitle clients to receive a specific health service from a specified group of accredited providers (which may include private sector providers), typically at no cost but sometimes at a subsidized cost. For several decades, vouchers have been used to increase access to a wide range of services and commodities, including bed nets, HIV testing, antenatal and delivery care, and family planning. Voucher programs are a pathway to improved strategic purchasing of health services and can be an intermediary step to establishing contractual arrangements with private providers.
CCTs enable individuals or families to receive a payment after they have fulfilled certain conditions, such as participating in a health promotion class or using specific health services. Such transfers are now commonplace in developing countries and have been used for a wide range of health services and for education (e.g., school attendance). These programs tend to operate at scale and for long periods of time, as opposed to vouchers and other interventions that tend to be piloted for short periods of time. The overall costs of CCTs are high, making them potentially more feasible to implement in upper-middle income countries compared with low- or lower-middle income countries.
As with other financing schemes, designers of voucher and CCT programs must take care to ensure informed choice and to promote the quality of services, not just the quantity. Moreover, such programs require significant investment in systems to register and monitor providers, define benefits and reimbursement rates, identify and reach targeted populations, validate use of services, and make timely payments. Voucher programs in particular are mostly donor-funded, raising concerns about their sustainability. In a study of 40 voucher programs, over a quarter were initiated by a donor. In Africa and Latin America, most programs were initiated by social franchising organizations, nongovernmental organizations, or research institutes with donor support.
How Do Vouchers and CCTs Affect Use of Family Planning?
Vouchers can help clients overcome financial barriers to accessing services and increase the number and types of providers offering quality services, resulting in improved family planning access and use (Figure 1). They can help expand method choice by reducing out-of-pocket costs, particularly for higher cost methods such as long-acting reversible contraceptives (LARCs) and permanent methods (PMs), or by subsidizing user fees associated with private facilities. However, recent systematic reviews show mixed findings on vouchers’ impact on family planning use and other outcomes. For example, they may lead to unintended consequences on other service provision, strain administrative resources, deemphasize integrated approaches, and overwhelm providers with increased demand. Quality assurance and financial reimbursement mechanisms, nonuse of vouchers, and contraceptive discontinuation are usually overlooked or not measured in evaluations of voucher programs. Most favorable outcomes can be achieved when voucher programs comprehensively consider and boost supply (by equipping providers and facilities to provide quality services) and demand (by appropriately targeting and connecting underserved clients to facilities).
Figure 1. Theory of Change for Contraceptive Vouchers
Source: High Impact Practices Brief
CCT programs typically have broad social protection and poverty reduction aims, and they motivate behavior change by rewarding individuals or households with a payment upon use of a specific set of services. CCT programs do not generally condition payment on use of contraceptive services, and USAID rules do not allow CCT programs to link payment with uptake of a method. Rather, CCT programs typically require that women seek periodic health checkups that may or may not include family planning services. Only one study, of the Oportunidades CCT program in Mexico, found that contraceptive use was higher among those exposed to the program than among those unexposed. Others show no impact on family planning or fertility behaviors, perhaps because they do not pay for method uptake.
Sustainability Implications of Voucher and CCT Programs in Relation to Family Planning
As countries face transitions in donor funding, they may need to mobilize domestic resources or make changes to existing financial arrangements to sustain the impact of voucher programs. Continued funding for voucher programs is critical in countries that have low contraceptive use, immature health financing systems (e.g., that do not allow for integration of vouchers in other financing schemes), and demonstrable evidence that current voucher programs are increasing utilization of family planning services. In these countries, family planning stakeholders should advocate for government funding of existing voucher programs. While many countries have introduced budget line items for family planning commodities, few have budgets for interventions such as vouchers. Therefore, evidence on the costs of such programs and their health, social, and economic impacts is needed to convince governments to invest in family planning voucher programs.
Alternatively, in countries with more mature health financing systems and growing demand for family planning, voucher programs could potentially be integrated into broader strategic purchasing for health arrangements, such as contracting with private providers. Under certain conditions, this approach is potentially more efficient and sustainable than securing a separate funding stream just for family planning vouchers.
Unlike vouchers, CCT programs are typically funded by domestic financing sources and designed to be implemented at scale for long periods of time. Therefore, securing continued government funding for such programs may not be an issue in many countries. However, funding may be needed to expand the program to cover additional individuals or households or reimbursement for use of additional services. Since these programs are not focused exclusively on specific health areas, family planning stakeholders may need to advocate for consideration of family planning services in the design or expansion of the programs.