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1.  An assessment of opportunities and challenges for public sector involvement in the maternal health voucher program in Uganda 
Background
Continued inequities in coverage, low quality of care, and high out-of-pocket expenses for health services threaten attainment of Millennium Development Goals 4 and 5 in many sub-Saharan African countries. Existing health systems largely rely on input-based supply mechanisms that have a poor track record meeting the reproductive health needs of low-income and underserved segments of national populations. As a result, there is increased interest in and experimentation with results-based mechanisms like supply-side performance incentives to providers and demand-side vouchers that place purchasing power in the hands of low-income consumers to improve uptake of facility services and reduce the burden of out-of-pocket expenditures. This paper describes a reproductive health voucher program that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the program to include public sector facilities.
Methods
Data presented here describes the results of interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher program in southwestern Uganda. Interviews were transcribed and organized thematically, barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the program by involving public sector facilities were investigated.
Results
The findings show that access to sexual and reproductive health services in southwestern Uganda is constrained by both facility and individual level factors which can be addressed by inclusion of the public facilities in the program. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher program with other services is likely to address some of the barriers. The public sector facilities were also seen as being well positioned to provide voucher services because of their countrywide reach, enhanced infrastructure, and referral networks. The voucher program also has the potential to address public sector constraints such as understaffing and supply shortages.
Conclusions
Accrediting public facilities has the potential to increase voucher program coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening linkages between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilization of resources to support the sustainability of the programs. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher program.
doi:10.1186/1478-4505-11-38
PMCID: PMC3853937  PMID: 24139603
Challenges; Maternal health; Opportunities; Output-based approach; Public sector engagement; Reproductive health; Vouchers
2.  Mass distribution of free insecticide-treated nets do not interfere with continuous net distribution in Tanzania 
Malaria Journal  2014;13:196.
Background
To protect the most vulnerable groups from malaria (pregnant women and infants) the Tanzanian Government introduced a subsidy (voucher) scheme in 2004, on the basis of a public-private partnership. These vouchers are provided to pregnant women at their first antenatal care visit and mothers of infants at first vaccination. The vouchers are redeemed at registered retailers for a long-lasting insecticidal net against the payment of a modest top-up price. The present work analysed a large body of data from the Tanzanian National Voucher Scheme, focusing on interactions with concurrent mass distribution campaigns of free nets.
Methods
In an ecologic study involving all regions of Tanzania, voucher redemption data for the period 2007 2011, as well as data on potential determinants of voucher redemption were analysed. The four outcome variables were: pregnant woman and infant voucher redemption rates, use of treated bed nets by all household members and by under- five children. Each of the outcomes was regressed with selected determinants, using a generalized estimating equation model and accounting for regional data clustering.
Results
There was a consistent improvement in voucher redemption rates over the selected time period, with rates >80% in 2011. The major determinants of redemption rates were the top-up price paid by the voucher beneficiary, the retailer- clinic ratio, and socio-economic status. Improved redemption rates after 2009 were most likely due to reduced top-up prices (following a change in policy). Redemption rates were not affected by two major free net distribution campaigns. During this period, there was a consistent improvement in net use across all the regions, with rates of up to 75% in 2011.
Conclusion
The key components of the National Treated Nets Programme (NATNETS) seem to work harmoniously, leading to a high level of net use in the entire population. This calls for the continuation of this effort in Tanzania and for emulation by other countries with endemic malaria.
doi:10.1186/1475-2875-13-196
PMCID: PMC4046070  PMID: 24884786
Malaria; Malaria control; Voucher scheme; Long-lasting insecticidal nets; Ecological study; Tanzania
3.  Lessons from sexual and reproductive health voucher program design and function: a comprehensive review 
Background
Developing countries face challenges in financing healthcare; often the poor do not receive the most basic services. The past decade has seen a sharp increase in the number of voucher programs, which target output-based subsidies for specific services to poor and underserved groups. The dearth of literature that examines lessons learned risks the wheel being endlessly reinvented. This paper examines commonalities and differences in voucher design and implementation, highlighting lessons learned for the design of new voucher programmes.
Methodology
The methodology comprised: discussion among key experts to develop inclusion/exclusion criteria; up-dating the literature database used by the DFID systematic review of voucher programs; and networking with key contacts to identify new programs and obtain additional program documents. We identified 40 programs for review and extracted a dataset of more than 120 program characteristics for detailed analysis.
Results
All programs aimed to increase utilisation of healthcare, particularly maternal health services, overwhelmingly among low-income populations. The majority contract(ed) private providers, or public and private providers, and all facilitate(d) access to services that are well defined, time-limited and reflect the country’s stated health priorities.
All voucher programs incorporate a governing body, management agency, contracted providers and target population, and all share the same incentive structure: the transfer of subsidies from consumers to service providers, resulting in a strong effect on both consumer and provider behaviour. Vouchers deliver subsidies to individuals, who in the absence of the subsidy would likely not have sought care, and in all programs a positive behavioural response is observed, with providers investing voucher revenue to attract more clients. A large majority of programs studied used targeting mechanisms.
Conclusions
While many programs remain too small to address national-level need among the poor, large programs are being developed at a rate of one every two years, with further programs in the pipeline. The importance of addressing inequalities in access to basic services is recognized as an important component in the drive to achieve universal health coverage; vouchers are increasingly acknowledged as a promising targeting mechanism in this context, particularly where social health insurance is not yet feasible.
doi:10.1186/1475-9276-13-33
PMCID: PMC4024100  PMID: 24779653
Results-based financing; Demand-side financing; Sexual and reproductive health; Maternal health; Voucher program; Social franchising; Poverty targeting; Social health insurance; Incentives; Subsidies
4.  A Taxonomy and Results from a Comprehensive Review of 28 Maternal Health Voucher Programmes 
Journal of Health, Population, and Nutrition  2013;31(4 Suppl 2):S106-S128.
It is increasingly clear that Millennium Development Goal 4 and 5 will not be achieved in many low- and middle-income countries with the weakest gains among the poor. Recognizing that there are large inequalities in reproductive health outcomes, the post-2015 agenda on universal health coverage will likely generate strategies that target resources where maternal and newborn deaths are the highest. In 2012, the United States Agency for International Development convened an Evidence Summit to review the knowledge and gaps on the utilization of financial incentives to enhance the quality and uptake of maternal healthcare. The goal was to provide donors and governments of the low- and middle-income countries with evidence-informed recommendations on practice, policy, and strategies regarding the use of financial incentives, including vouchers, to enhance the demand and supply of maternal health services. The findings in this paper are intended to guide governments interested in maternal health voucher programmes with recommendations for sustainable implementation and impact. The Evidence Summit undertook a systematic review of five financing strategies. This paper presents the methods and findings for vouchers, building on a taxonomy to catalogue knowledge about voucher programme design and functionality. More than 120 characteristics under five major categories were identified: programme principles (objectives and financing); governance and management; benefits package and beneficiary targeting; providers (contracting and service pricing); and implementation arrangements (marketing, claims processing, and monitoring and evaluation). Among the 28 identified maternal health voucher programmes, common characteristics included: a stated objective to increase the use of services among the means-tested poor; contracted-out programme management; contracting either exclusively private facilities or a mix of public and private providers; prioritizing community-based distribution of vouchers; and tracking individual claims for performance purposes. Maternal voucher programmes differed on whether contracted providers were given training on clinical or administrative issues; whether some form of service verification was undertaken at facility or community-level; and the relative size of programme management costs in the overall programme budget. Evidence suggests voucher programmes can serve populations with national-level impact. Reaching scale depends on whether the voucher programme can: (i) keep management costs low, (ii) induce a large demand-side response among the bottom two quintiles, and (iii) achieve a quality of care that translates a greater number of facility-based deliveries into a reduction in maternal morbidity and mortality.
PMCID: PMC4021701
Demand-side financing; Maternal healthcare; Results-based financing; Vouchers
5.  Evaluation of the impact of the voucher and accreditation approach on improving reproductive health behaviors and status in Kenya 
BMC Public Health  2011;11:177.
Abtsract
Background
Alternatives to the traditional 'supply-side' approach to financing service delivery are being explored. These strategies are termed results-based finance, demand-side health financing or output-based aid which includes a range of interventions that channel government or donor subsidies to the user rather than the provider. Initial pilot assessments of reproductive health voucher programs suggest that, they can increase access and use, reducing inequities and enhancing program efficiency and service quality. However, there is a paucity of evidence describing how the programs function in different settings, for various reproductive health services. Population Council, funded by the Bill and Melinda Gates Foundation, intends to generate evidence around the 'voucher and accreditation' approaches to improving the reproductive health of low income women in Kenya.
Methods/Design
A quasi-experimental study will investigate the impact of the voucher approach on improving reproductive health behaviors, reproductive health status and reducing inequities at the population level; and assessing the effect of vouchers on increasing access to, and quality of, and reducing inequities in the use of selected reproductive health services. The study comprises of four populations: facilities, providers, women of reproductive health age using facilities and women and men who have been pregnant and/or used family planning within the previous 12 months. The study will be carried out in samples of health facilities - public, private and faith-based in: three districts; Kisumu, Kiambu, Kitui and two informal settlements in Nairobi which are accredited to provide maternal and newborn health and family planning services to women holding vouchers for the services; and compared with a matched sample of non-accredited facilities. Health facility assessments (HFA) will be conducted at two stages to track temporal changes in quality of care and utilization. Facility inventories, structured observations, and client exit interviews will be used to collect comparable data across facilities. Health providers will also be interviewed and observed providing care. A population survey of about 3000 respondents will also be carried out in areas where vouchers are distributed and similar locations where vouchers are not distributed.
doi:10.1186/1471-2458-11-177
PMCID: PMC3074544  PMID: 21429207
Vouchers; Out-put based approach
6.  Quality of Private and Public Ambulatory Health Care in Low and Middle Income Countries: Systematic Review of Comparative Studies 
PLoS Medicine  2011;8(4):e1000433.
Paul Garner and colleagues conducted a systematic review of 80 studies to compare the quality of private versus public ambulatory health care in low- and middle-income countries.
Background
In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options.
Methods and Findings
We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred.
Conclusions
Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The provision of private (“for-profit” hospitals and self-employed practitioners, and “not-for-profit” non-government providers, including faith-based organizations) versus public health care services in low and middle income countries raises considerable ideological debate. Ideological arguments aside—which can be very passionate on both sides—there is general agreement that improving the quality of both public and private health care could have a major impact on improved health outcomes, especially as the private sector is so widely used in low and middle income countries. For example, almost three quarters and half of children from the poorest households of South Asia and sub-Saharan Africa, respectively, seek health care from a private provider when they are ill. Private providers are also increasingly responsible for outpatient care for non-communicable diseases.
As a result of the mixed health care system in many low and middle income countries, adequate oversight and stewardship of the mixed system from the national government is essential yet often missing.
Why Was This Study Done?
An understanding of how quality and performance in the private sector compares with that in the public sector would help governments to prioritize where they need to concentrate their efforts. So, for example, if the private sector is generally providing poorer quality care than the public sector, then there is an imperative to improve the quality and outcomes; on the other hand, if the quality of care offered by the private sector is good, the policy priority is to influence the market to further improve access to such health care for low income groups.
In order to help with this comparison, the researchers wanted to systematically identify and summarize the results of studies that directly compared the quality of care offered by public providers with the one offered by “formal” private providers (recognized by law) and “informal” private providers (providers that are not legally recognized, such as lay health workers and shop keepers). For the purposes of this study the researchers focused their comparison on the private and public provision of outpatient care in low and middle income countries.
What Did the Researchers Do and Find?
In their literature review, the researchers searched for relevant studies reported in English, French, or German and published between January 1970 and April 2009. Only studies that compared private and public outpatient medical services in the same country, at the same time, using the same methods, and which met particular quality criteria, were included in the analysis. The researchers also had strict criteria for including qualitative studies, and they retrieved the full text of articles, contacted study authors where appropriate, and verified with a second researcher most (80%) of the extracted study data. In order to evaluate and compare the studies, the researchers converted study values to a linear 100% scale, calculated differences between providers within studies, and summarized the median values of the differences across studies.
The researchers identified a total of 8,812 relevant titles and abstracts and found 80 studies that included direct quantitative comparisons of public and private formal providers. Ten studies included qualitative data. Most studies were conducted after 1990, and mainly in sub-Saharan Africa (n = 39) and Asia and the Pacific (n = 23). Most studies did not report socio-economic status of public and private service users, and only five studies presented data by different income groups. No study compared the same individual providers working in public and private care settings. Only two studies compared public providers and private informal providers, so the authors excluded these from subsequent analysis.
For the formal sector, since the results for “for-profit” and “not-for-profit” providers were similar, the researchers decided to combine the results. Overall, the researchers found that the median values indicated that many services, irrespective of whether public or private, scored low (less than 50%) on infrastructure, clinical competence, and practice. Generally, the private sector performed better in relation to drug supply, responsiveness, and effort, but there was no detectable difference between provider groups for patient satisfaction. Furthermore, a synthesis of qualitative data suggested that the private sector may be more client-centered.
What Do These Findings Mean?
Based on the findings of this review, there is a clear need to consider the quality of primary health services in both the public and private sector in order to improve health outcomes in low and middle income countries. These findings also indicate that, for some aspects of care, on average the private sector provided better quality services. The overall low quality of care in both the formal private and public sector found in this review is worrying, and calls for the governments of low and middle income countries to find and implement effective strategies to improve the quality in both sectors. This is particularly important given the increasing volume of conditions that require relatively sophisticated, long-term ambulatory medical care, such as non-communicable diseases.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000433.
This study is further discussed in a PLoS Medicine Perspective by Jishnu Das
WHO has more information on health service delivery in low- and middle-income countries
WHO has more information on noncommunicable diseases
The World Bank's World Development Report for 2004 addresses health care for poor people
doi:10.1371/journal.pmed.1000433
PMCID: PMC3075233  PMID: 21532746
7.  Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review 
PLoS Medicine  2012;9(6):e1001244.
A systematic review conducted by Sanjay Basu and colleagues reevaluates the evidence relating to comparative performance of public versus private sector healthcare delivery in low- and middle-income countries.
Introduction
Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.
Methods and Findings
Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. “Competitive dynamics” for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.
Conclusions
Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Health care can be provided through public and private providers. Public health care is usually provided by the government through national healthcare systems. Private health care can be provided through “for profit” hospitals and self-employed practitioners, and “not for profit” non-government providers, including faith-based organizations.
There is considerable ideological debate around whether low- and middle-income countries should strengthen public versus private healthcare services, but in reality, most low- and middle-income countries use both types of healthcare provision. Recently, as the global economic recession has put major constraints on government budgets—the major funding source for healthcare expenditures in most countries—disputes between the proponents of private and public systems have escalated, further fuelled by the recommendation of International Monetary Fund (an international finance institution) that countries increase the scope of private sector provision in health care as part of loan conditions to reduce government debt. However, critics of the private health sector believe that public healthcare provision is of most benefit to poor people and is the only way to achieve universal and equitable access to health care.
Why Was This Study Done?
Both sides of the public versus private healthcare debate draw on selected case reports to defend their viewpoints, but there is a widely held view that the private health system is more efficient than the public health system. Therefore, in order to inform policy, there is an urgent need for robust evidence to evaluate the quality and effectiveness of the health care provided through both systems. In this study, the authors reviewed all of the evidence in a systematic way to evaluate available data on public and private sector performance.
What Did the Researchers Do and Find?
The researchers used eight databases and a comprehensive key word search to identify and review appropriate published data and studies of private and public sector performance in low- and middle-income countries. They assessed selected studies against the World Health Organization's six essential themes of health systems—accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency—and conducted a narrative review of each theme.
Out of the 102 relevant studies included in their comparative analysis, 59 studies were research studies and 13 involved meta-analysis, with the rest involving case reports or reviews. The researchers found that study findings varied considerably across countries studied (one-third of studies were conducted in Africa and a third in Southeast Asia) and by the methods used.
Financial barriers to care (such as user fees) were reported for both public and private systems. Although studies report that patients in the private sector experience better timeliness and hospitality, studies suggest that providers in the private sector more frequently violate accepted medical standards and have lower reported efficiency.
What Do These Findings Mean?
This systematic review did not support previous views that private sector delivery of health care in low- and middle-income settings is more efficient, accountable, or effective than public sector delivery. Each system has its strengths and weaknesses, but importantly, in both sectors, there were financial barriers to care, and each had poor accountability and transparency. This systematic review highlights a limited and poor-quality evidence base regarding the comparative performance of the two systems.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001244.
A previous PLoS Medicine study examined the outpatient care provided by the public and private sector in low-income countries
The WHO website provides more information on healthcare systems
The World Bank website provides information on health system financing
Oxfam provides an argument against increased private health care in poor countries
doi:10.1371/journal.pmed.1001244
PMCID: PMC3378609  PMID: 22723748
8.  Impact of Social Franchising on Contraceptive Use When Complemented by Vouchers: A Quasi-Experimental Study in Rural Pakistan 
PLoS ONE  2013;8(9):e74260.
Background
Pakistan has had a low contraceptive prevalence rate for the last two decades; with preference for natural birth spacing methods and condoms. Family planning services offered by the public sector have never fulfilled the demand for contraception, particularly in rural areas. In the private sector, cost is a major constraint. In 2008, Marie Stopes Society – a local NGO started a social franchise programme along with a free voucher scheme to promote uptake of IUCDs amongst the poor. This paper evaluates the effectiveness of this approach, which is designed to increase modern long term contraceptive awareness and use in rural areas of Pakistan.
Methodology
We used a quasi-experimental study design with controls, selecting one intervention district and one control district from the Sindh and Punjab provinces. In each district, we chose a total of four service providers. A baseline survey was carried out among 4,992 married women of reproductive age (MWRA) in February 2009. Eighteen months after the start of intervention, an independent endline survey was conducted among 4,003 women. We used multilevel logistic regression for analysis using Stata 11.
Results
Social franchising used alongside free vouchers for long term contraceptive choices significantly increased the awareness of modern contraception. Awareness increased by 5% in the intervention district. Similarly, the ever use of modern contraceptive increased by 28.5%, and the overall contraceptive prevalence rate increased by 19.6%. A significant change (11.1%) was recorded in the uptake of IUCDs, which were being promoted with vouchers.
Conclusion
Family planning franchise model promotes awareness and uptake of contraceptives. Moreover, supplemented with vouchers, it may enhance the use of IUCDs, which have a significant cost attached. Our research also supports a multi-pronged approach- generating demand through counselling, overcoming financial constraints by offering vouchers, training, accreditation and branding of the service providers, and ensuring uninterrupted contraceptive supplies.
doi:10.1371/journal.pone.0074260
PMCID: PMC3772094  PMID: 24069287
9.  Evaluation of the impact of the voucher and accreditation approach on improving reproductive behaviors and RH status: Bangladesh 
BMC Public Health  2011;11:257.
Background
Cost of delivering reproductive health services to low-income populations will always require total or partial subsidization by the government and/or development partners. Broadly termed "Demand-Side Financing" or "Output-Based Aid", includes a range of interventions that channel government or donor subsidies to the service user rather than the service provider. Initial findings from the few assessments of reproductive health voucher-and-accreditation programs suggest that, if implemented well, these programs have great potential for achieving the policy objectives of increasing access and use, reducing inequities and enhancing program efficiency and service quality. At this point in time, however, there is a paucity of evidence describing how the various voucher programs function in different settings, for various reproductive health services.
Methods/Design
Population Council-Nairobi, funded by the Bill and Melinda Gates Foundation, intends to address the lack of evidence around the pros and cons of 'voucher and accreditation' approaches to improving the reproductive health of low income women in five developing countries. In Bangladesh, the activities will be conducted in 11 accredited health facilities where Demand Side Financing program is being implemented and compared with populations drawn from areas served by similar non-accredited facilities. Facility inventories, client exit interviews and service provider interviews will be used to collect comparable data across each facility for assessing readiness and quality of care. In-depth interviews with key stakeholders will be conducted to gain a deeper understanding about the program. A population-based survey will also be carried out in two types of locations: areas where vouchers are distributed and similar locations where vouchers are not distributed.
Discussion
This is a quasi-experimental study which will investigate the impact of the voucher approach on improving maternal health behaviors and status and reducing inequities at the population level. We expect a significant increase in the utilization of maternal health care services by the accredited health facilities in the experimental areas compared to the control areas as a direct result of the interventions. If the voucher scheme in Bangladesh is found effective, it may help other countries to adopt this approach for improving utilization of maternity care services for reducing maternal mortality.
doi:10.1186/1471-2458-11-257
PMCID: PMC3103455  PMID: 21513528
10.  Redeeming qualities: exploring factors that affect women’s use of reproductive health vouchers in Cambodia 
Background
One approach to delivering healthcare in developing countries is through voucher programs, where vouchers are distributed to a specific population for free or subsidized health care. Recent evaluations suggest that vouchers have the potential to extend coverage of priority health services to the poor in developing countries. In Cambodia, a reproductive health voucher program was implemented in January 2011. This study aims to explore women’s early experiences accessing health services with their vouchers at accredited clinics.
Methods
This qualitative exploratory study used focus group methodology to gather information from five groups of older (>25 years) and four groups of younger (18–25 years) women who were eligible for the voucher program in three rural provinces. Focus groups were digitally recorded, transcribed and translated from Khmer into English. Data analysis was an iterative process, which comprised of open coding to find commonalities that reflected categories or themes and axial coding to relate initial themes to each other. Next, a basic framework for analysis was formed by integrating the themes into the framework.
Results
Two overarching themes were identified in the data: 1) factors that facilitate voucher use and 2) factors that inhibit voucher use. Within each of these themes, three subthemes were identified: 1) pre-existing factors, 2) distribution factors, and 3) redemption factors. Overall, women expressed positive feelings towards the voucher program, while several areas for program improvement were identified including the importance of addressing pre-existing demand-side barriers to using reproductive health services, the need for more comprehensive counselling during voucher distribution, and the persistent cost of unofficial payments expected by midwives after delivery irrespective of voucher use.
Conclusions
Early information from program beneficiaries can lead to timely and responsive changes that can help to maximize program success. This study highlights the importance of tailoring voucher programs to specific community needs, a strategy that can lead to better program uptake.
doi:10.1186/1472-698X-13-13
PMCID: PMC3599041  PMID: 23442446
11.  Evaluation of the impact of the voucher and accreditation approach on improving reproductive behaviors and status in Cambodia 
BMC Public Health  2011;11:667.
Background
Cost of delivering reproductive health services to low income populations will always require total or partial subsidization by government and/or development partners. Broadly termed "demand-side financing" or "output-based aid", these strategies include a range of interventions that channel government or donor subsidies to the user rather than the service provider. Initial pilot assessments of reproductive health voucher programs suggest that they can increase access, reduce inequities, and enhance program efficiency and service quality. However, there is a paucity of evidence describing how these programs function in different settings for various reproductive health services.
Methods/Design
Population Council, funded by the Bill and Melinda Gates Foundation, intends to generate evidence around the "voucher and accreditation" approaches to improving the reproductive health of low-income women in Cambodia. The study comprises of four populations: facilities, providers, women of reproductive age using facilities, and women and men who have been pregnant and/or used family planning within the previous 12 months. The study will be carried out in a sample of 20 health facilities that are accredited to provide maternal and newborn health and family planning services to women holding vouchers from operational districts in three provinces: Kampong Thom, Kampot and Prey Veng and a matched sample of non-accredited facilities in three other provinces. Health facility assessments will be conducted at baseline and endline to track temporal changes in quality-of-care, client out-of-pocket costs, and utilization. Facility inventories, structured observations, and client exit interviews will be used to collect comparable data across facilities. Health providers will also be interviewed and observed providing care. A population survey of about 3000 respondents will also be conducted in areas where vouchers are distributed and similar non-voucher locations.
Discussion
A quasi-experimental study will investigate the impact of the voucher approach on improving reproductive health behaviors, reproductive health status and reducing inequities at the population level and assess effects on access, equity and quality of care at the facility level. If the voucher scheme in Cambodia is found effective, it may help other countries adopt this approach for improving utilization and access to reproductive health and family planning services.
doi:10.1186/1471-2458-11-667
PMCID: PMC3170624  PMID: 21864405
Vouchers; Output based approach
12.  The role of insurance in the achievement of universal coverage within a developing country context: South Africa as a case study 
BMC Public Health  2012;12(Suppl 1):S5.
Background
Achieving universal coverage as an objective needs to confront the reality of multiple mechanisms, with healthcare financing and provision occurring in both public and private settings. South Africa has both large and mature public and private health systems offering useful insights into how they can be effectively harmonized to optimise coverage. Private healthcare in South Africa has also gone through many phases and regulatory regimes which, through careful review, can help identify potential policy frameworks that can optimise their ability to deepen coverage in a manner that complements the basic coverage of public arrangements.
Research question
Using South Africa as a case study, this review examines whether private health systems are susceptible to regulation and therefore able to support an extension and deepening of coverage when complementing a pre-existing publicly funded and delivered health system?
Methods
The approach involves a review of different stages in the development of the South African private health system and its response to policy changes. The focus is on the time-bound characteristics of the health system and associated policy responses and opportunities. A distinction is consequently made between the early, largely unregulated, phases of development and more mature phases with alternative regulatory regimes.
Results
The private health system in South Africa has played an important supplementary role in achieving universal coverage throughout its history, but more especially in the post-Apartheid period. However, the quality of this role has been erratic, influenced predominantly by policy vacillation.
The private system expanded rapidly during the 1980s mainly due to the pre-existence of a mature health insurance system and a weakening public hospital system which could accommodate and facilitate an increased demand for private hospital services. This growth served to expand commercial interest in health insurance, in the form of regulated medical schemes, which until this point took the form of non-commercial occupational (employer-based) schemes. During the 1980s government acquiesced to industry lobbies arguing for the deregulation of health insurance from 1989, with an extreme deregulation occurring in 1994, evidently in anticipation of the change of government associated with the democratic dispensation. Dramatic unintended consequences followed, with substantial increases in provider and funder costs coinciding with uncontrolled discrimination against poor health risks.
Against significant industry opposition, including legal challenges, partial re-regulation took effect from 2000 which removed the discretion of schemes to discriminate against poor health risks. This included: the implementation of a strong regulator of health insurance; the establishment of one allowable vehicle able to provide health insurance; open enrolment, whereby schemes could not refuse membership applications; mandatory minimum benefit requirements; and a prohibition on setting contributions or premiums on the basis of health status. After a two-year lag, dramatically reduced cost trends and contributions became evident. Aside from generally tighter regulation across a range of fronts, this appears related to the need for schemes to compete more on the basis of healthcare provider costs than demographic risk profiles. Despite an incomplete reform improved equitable coverage and cost-containment was nevertheless achieved.
A more complete regulatory regime is consequently likely to deepen coverage by: further stabilising and even decreasing costs; enhanced risk pooling; and access for low income groups. This would occur if South Africa: improved the quality of free public services, thereby creating competitive constraints for medical schemes; introduced risk-equalisation, increasing the pressure on schemes to compete on the cost and quality of coverage rather than their risk profile; and through the establishment of improved price regulation.
Conclusions
The objective of universal coverage can be seen in two dimensions, horizontal extension and vertical deepening. Private systems play an important role in deepening coverage by mobilising revenue from income earners for health services over-and-above the horizontal extension role of public systems and related subsidies. South Africa provides an example of how this natural deepening occurs whether regulated or unregulated. It also demonstrates how poor regulation of mature private systems can severely undermine this role and diminish achievements below attainable levels of social protection. The mature South African system has demonstrated its sensitivity to regulatory design and responds rapidly to changes both positive and negative. When measures to enhance risk pooling are introduced, coverage is expanded and becomes increasingly fair and sustainable. When removed, however, the system becomes less stable and fair as costs rise and people with poor health status are systematically excluded from cover. This susceptibility to regulation therefore presents an opportunity to policymakers to achieve social protection objectives through the strategic management of markets rather than exclusively through less responsive systems based on tax-funded direct provision. This is especially relevant as private markets for healthcare are inevitable, with policy discretion reduced to a choice between functional or dysfunctional regimes.
doi:10.1186/1471-2458-12-S1-S5
PMCID: PMC3381693  PMID: 22992410
13.  Incremental cost of increasing access to maternal health care services: perspectives from a demand and supply side intervention in Eastern Uganda 
Introduction
High maternal and infant mortality continue to be major challenges to the attainment of the Millennium Development Goals for many low and middle-income countries. There is now evidence that voucher initiatives can increase access to maternal health services. However, a dearth of knowledge exists on the cost implications of voucher schemes. This paper estimates the incremental costs of a demand and supply side intervention aimed at increasing access to maternal health care services.
Methods
This costing study was part of a quasi-experimental voucher study conducted in two districts in Eastern Uganda to explore the impact of demand and supply - side incentives on increasing access to maternal health services. The provider’s perspective was used and the ingredients approach to costing was employed. Costs were based on market prices as recorded in program records. Total, unit, and incremental costs were calculated.
Results
The estimated total financial cost of the intervention for the one year of implementation was US$525,472 (US$1 = 2200UgShs). The major cost drivers included costs for transport vouchers (35.3%), health system strengthening (29.2%) and vouchers for maternal health services (18.2%). The average cost of transport per woman to and from the health facility was US$4.6. The total incremental costs incurred on deliveries (excluding caesarean section) was US$317,157 and US$107,890 for post natal care (PNC). The incremental costs per additional delivery and PNC attendance were US$23.9 and US$7.6 respectively.
Conclusion
Subsidizing maternal health care costs through demand and supply – side initiatives may not require significant amounts of resources contrary to what would be expected. With Uganda’s Gross Domestic Product (GDP) per capita of US$55` (2012), the incremental cost per additional delivery (US$23.9) represents about 5% of GDP per capita to save a mother and probably her new born. For many low income countries, this may not be affordable, yet reliance on donor funding is often not sustainable. Alternative ways of raising additional resources for health must be explored. These include; encouraging private investments in critical sectors such as rural transport, health service provision; mobilizing households to save financial resources for preparedness, and financial targeting for the most vulnerable.
doi:10.1186/1478-7547-12-14
PMCID: PMC4074383  PMID: 24976793
Vouchers; Maternal health; Costs; Sustainability; Demand-side; Supply-side
14.  The Importance of Implementation Strategy in Scaling Up Xpert MTB/RIF for Diagnosis of Tuberculosis in the Indian Health-Care System: A Transmission Model 
PLoS Medicine  2014;11(7):e1001674.
Using a modelling approach, David Dowdy and colleagues investigate how different implementation strategies for Xpert MTB/RIF within the complex, fragmented healthcare system of India may affect tuberculosis control.
Please see later in the article for the Editors' Summary
Background
India has announced a goal of universal access to quality tuberculosis (TB) diagnosis and treatment. A number of novel diagnostics could help meet this important goal. The rollout of one such diagnostic, Xpert MTB/RIF (Xpert) is being considered, but if Xpert is used mainly for people with HIV or high risk of multidrug-resistant TB (MDR-TB) in the public sector, population-level impact may be limited.
Methods and Findings
We developed a model of TB transmission, care-seeking behavior, and diagnostic/treatment practices in India and explored the impact of six different rollout strategies. Providing Xpert to 40% of public-sector patients with HIV or prior TB treatment (similar to current national strategy) reduced TB incidence by 0.2% (95% uncertainty range [UR]: −1.4%, 1.7%) and MDR-TB incidence by 2.4% (95% UR: −5.2%, 9.1%) relative to existing practice but required 2,500 additional MDR-TB treatments and 60 four-module GeneXpert systems at maximum capacity. Further including 20% of unselected symptomatic individuals in the public sector required 700 systems and reduced incidence by 2.1% (95% UR: 0.5%, 3.9%); a similar approach involving qualified private providers (providers who have received at least some training in allopathic or non-allopathic medicine) reduced incidence by 6.0% (95% UR: 3.9%, 7.9%) with similar resource outlay, but only if high treatment success was assured. Engaging 20% of all private-sector providers (qualified and informal [providers with no formal medical training]) had the greatest impact (14.1% reduction, 95% UR: 10.6%, 16.9%), but required >2,200 systems and reliable treatment referral. Improving referrals from informal providers for smear-based diagnosis in the public sector (without Xpert rollout) had substantially greater impact (6.3% reduction) than Xpert scale-up within the public sector. These findings are subject to substantial uncertainty regarding private-sector treatment patterns, patient care-seeking behavior, symptoms, and infectiousness over time; these uncertainties should be addressed by future research.
Conclusions
The impact of new diagnostics for TB control in India depends on implementation within the complex, fragmented health-care system. Transformative strategies will require private/informal-sector engagement, adequate referral systems, improved treatment quality, and substantial resources.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Tuberculosis—a contagious bacterial disease that usually infects the lungs—is a global public health problem. Each year, about 8.7 million people develop active tuberculosis and about 1.4 million people die from the disease. Mycobacterium tuberculosis, the bacterium that causes tuberculosis, is spread in airborne droplets when people with active disease cough or sneeze. The characteristic symptoms of tuberculosis are a persistent cough, fever, weight loss, and night sweats. Diagnostic tests for tuberculosis include sputum smear microscopy (microscopic analysis of mucus coughed up from the lungs), the growth of M. tuberculosis from sputum samples, and new molecular tests (for example, the automated Xpert MTB/RIF test) that rapidly and accurately detect M. tuberculosis in patient samples and determine its resistance to certain antibiotics. Tuberculosis can be cured by taking several antibiotics daily for at least six months, although the recent emergence of multidrug-resistant (MDR) tuberculosis is making the disease increasingly hard to treat.
Why Was This Study Done?
About 25% of all tuberculosis cases occur in India. Most people in India with underlying tuberculosis initially seek care for cough from the private health-care sector, which comprises informal providers with no formal medical training and providers with some training in mainstream or alternative medicine. Private providers rarely investigate for tuberculosis, and patients often move between providers, with long diagnostic delays. The public sector ultimately diagnoses and treats more than half of tuberculosis cases. However, the public sector relies on sputum smear microscopy, which misses half of cases, and the full diagnostic process from symptom onset to treatment initiation can take several months, during which time individuals remain infectious. Could the rollout of molecular diagnostic tests improve tuberculosis control in India? The Indian Revised National Tuberculosis Control Programme (RNTCP) is currently introducing the Xpert MTB/RIF test (Xpert) as a rapid method for drug susceptibility testing in the public sector in people at high risk of MDR tuberculosis, but is this the most effective rollout strategy? Here, the researchers use a mathematical transmission model to investigate the likely effects of the rollout of Xpert in India using different implementation strategies.
What Did the Researchers Do and Find?
The researchers explored the impact of several rollout strategies on the incidence of tuberculosis (the number of new cases of tuberculosis in the population per year) by developing a mathematical model of tuberculosis transmission, care-seeking behavior, and diagnostic/treatment practices in India. Compared to a baseline scenario of no improved diagnostic testing, provision of Xpert to 40% of public-sector patients at high risk of MDR tuberculosis (scenario 1, the current national strategy) reduced the incidence of tuberculosis by 0.2% and the incidence of MDR tuberculosis by 2.4%. Implementation of this strategy required 2,500 additional courses of MDR tuberculosis treatment and the continuous use of 60 Xpert machines, about half the machines procured in India during 2013. A scenario that added access to Xpert for 20% of all individuals with tuberculosis symptoms seeking diagnosis in the public sector and 20% of individuals seeking care from qualified private practitioners to scenario 1 reduced the incidence of tuberculosis by 14.1% compared to the baseline scenario but required more than 2,200 Xpert machines and reliable treatment referral. Notably, a scenario that encouraged informal providers to refer suspected tuberculosis cases to the public sector for smear-based diagnosis (no Xpert rollout) had a greater impact on the incidence of tuberculosis than Xpert scale-up within the public sector.
What Do These Findings Mean?
These findings are subject to considerable uncertainty because of the assumptions made in the transmission model about private-sector treatment patterns, patient care-seeking behavior, and infectiousness, and the quality of the data fed into the model. Nevertheless, these findings suggest that the rollout of Xpert (or other new diagnostic methods with similar characteristics) could substantially reduce the burden of tuberculosis due to poor diagnosis in India. Importantly, these findings highlight how the impact of Xpert rollout relies not only on the accuracy of the test but also on the behavior of patients and providers, the level of access to new tools, and the availability of treatment following diagnosis. Thus, to ensure that new diagnostic methods have the maximum impact on tuberculosis in India, it is necessary to engage the whole private health-care sector and to provide adequate referral systems, improved treatment quality, and increased resources across all health-care sectors.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001674.
The World Health Organization (WHO) provides information (in several languages) on all aspects of tuberculosis, including general information on tuberculosis diagnostics and specific information on the roll out of the Xpert MTB/RIF test; further information about WHO's endorsement of Xpert MTB/RIF is included in a Strategic and Technical Advisory Group for Tuberculosis report; the Global Tuberculosis Report 2013 provides information about tuberculosis around the world, including in India
The Stop TB Partnership is working towards tuberculosis elimination and provides patient stories about tuberculosis (in English and Spanish); the Tuberculosis Vaccine Initiative (a not-for-profit organization) also provides personal stories about tuberculosis
The US Centers for Disease Control and Prevention has information about tuberculosis and its diagnosis (in English and Spanish)
The US National Institute of Allergy and Infectious Diseases also has detailed information on all aspects of tuberculosis
TBC India provides information about tuberculosis control in India, including information on the RNTCP
The Initiative for Promoting Affordable and Quality TB Tests promotes WHO-endorsed TB tests in India
MedlinePlus has links to further information about tuberculosis (in English and Spanish)
doi:10.1371/journal.pmed.1001674
PMCID: PMC4098913  PMID: 25025235
15.  Age, chronic non-communicable disease and choice of traditional Chinese and western medicine outpatient services in a Chinese population 
Background
In 1997 Hong Kong reunified with China and the development of traditional Chinese medicine (TCM) started with this change in national identity. However, the two latest discussion papers on Hong Kong's healthcare reform have failed to mention the role of TCM in primary healthcare, despite TCM's public popularity and its potential in tackling the chronic non-communicable disease (NCD) challenge in the ageing population. This study aims to describe the interrelationship between age, non-communicable disease (NCD) status, and the choice of TCM and western medicine (WM) services in the Hong Kong population.
Methods
This study is a secondary analysis of the Thematic Household Survey (THS) 2005 dataset. The THS is a Hong Kong population representative face to face survey was conducted by the Hong Kong Administrative Region Government of China. A random sample of respondents aged >15 years were invited to report their use of TCM and WM in the past year, together with other health and demographic information. A total of 33,263 persons were interviewed (response rate 79.2%).
Results
Amongst those who received outpatient services in the past year (n = 18,087), 80.23% only visited WM doctors, 3.17% consulted TCM practitioners solely, and 16.60% used both type of services (double consulters). Compared to those who only consulted WM doctor, multinomial logistic regression showed that double consulters were more likely to be older, female, NCD patients, and have higher socioeconomic backgrounds. Further analysis showed that the association between age and double consulting was curvilinear (inverted U shaped) regardless of NCD status. Middle aged (45-60 years) NCD patients, and the NCD free "young old" group (60-75 years) were most likely to double consult. On the other hand, the relationship between age and use of TCM as an alternative to WM was linear regardless of NCD status. The NCD free segment of the population was more inclined to use TCM alone as they become older.
Conclusion
In Hong Kong, most patients have chosen WM provided in the public sector as their sole outpatient service provider for NCD. Amongst TCM service users, middle aged NCD patients are more likely to choose both TCM and WM outpatient services. Meanwhile, older people without NCD are more likely to use TCM as their main form of care, but the size of this population group is small. These utilization patterns show that patients choose both modalities to manage their NCD and TCM should be considered within policies for supporting patients with NCD under the wider primary health and social care system that supports patient choice.
doi:10.1186/1472-6963-9-207
PMCID: PMC2779812  PMID: 19917139
16.  Does a competitive voucher program for adolescents improve the quality of reproductive health care? A simulated patient study in Nicaragua 
BMC Public Health  2006;6:204.
Background
Little is known about how sexual and reproductive (SRH) health can be made accessible and appropriate to adolescents. This study evaluates the impact and sustainability of a competitive voucher program on the quality of SRH care for poor and underserved female adolescents and the usefulness of the simulated patient (SP) method for such evaluation.
Methods
28,711 vouchers were distributed to adolescents in disadvantaged areas of Managua that gave free-of-charge access to SRH care in 4 public, 10 non-governmental and 5 private clinics. Providers received training and guidelines, treatment protocols, and financial incentives for each adolescent attended. All clinics were visited by female adolescent SPs requesting contraception. SPs were sent one week before, during (with voucher) and one month after the intervention. After each consultation they were interviewed with a standardized questionnaire. Twenty-one criteria were scored and grouped into four categories. Clinics' scores were compared using non-parametric statistical methods (paired design: before-during and before-after). Also the influence of doctors' characteristics was tested using non-parametric statistical methods.
Results
Some aspects of service quality improved during the voucher program. Before the program started 8 of the 16 SPs returned 'empty handed', although all were eligible contraceptive users. During the program 16/17 left with a contraceptive method (p = 0.01). Furthermore, more SPs were involved in the contraceptive method choice (13/17 vs.5/16, p = 0.02). Shared decision-making on contraceptive method as well as condom promotion had significantly increased after the program ended.
Female doctors had best scores before- during and after the intervention. The improvements were more pronounced among male doctors and doctors older than 40, though these improvements did not sustain after the program ended.
Conclusion
This study illustrates provider-related obstacles adolescents often face when requesting contraception. The care provided during the voucher program improved for some important outcomes. The improvements were more pronounced among providers with the weakest initial performance. Shared decision-making and condom promotion were improvements that sustained after the program ended. The SP method is suitable and relatively easy to apply in monitoring clinics' performance, yielding important and relevant information. Objective assessment of change through the SP method is much more complex and expensive.
doi:10.1186/1471-2458-6-204
PMCID: PMC1559604  PMID: 16893463
17.  Uptake of Workplace HIV Counselling and Testing: A Cluster-Randomised Trial in Zimbabwe 
PLoS Medicine  2006;3(7):e238.
Background
HIV counselling and testing is a key component of both HIV care and HIV prevention, but uptake is currently low. We investigated the impact of rapid HIV testing at the workplace on uptake of voluntary counselling and testing (VCT).
Methods and Findings
The study was a cluster-randomised trial of two VCT strategies, with business occupational health clinics as the unit of randomisation. VCT was directly offered to all employees, followed by 2 y of open access to VCT and basic HIV care. Businesses were randomised to either on-site rapid HIV testing at their occupational clinic (11 businesses) or to vouchers for off-site VCT at a chain of free-standing centres also using rapid tests (11 businesses). Baseline anonymised HIV serology was requested from all employees.
HIV prevalence was 19.8% and 18.4%, respectively, at businesses randomised to on-site and off-site VCT. In total, 1,957 of 3,950 employees at clinics randomised to on-site testing had VCT (mean uptake by site 51.1%) compared to 586 of 3,532 employees taking vouchers at clinics randomised to off-site testing (mean uptake by site 19.2%). The risk ratio for on-site VCT compared to voucher uptake was 2.8 (95% confidence interval 1.8 to 3.8) after adjustment for potential confounders. Only 125 employees (mean uptake by site 4.3%) reported using their voucher, so that the true adjusted risk ratio for on-site compared to off-site VCT may have been as high as 12.5 (95% confidence interval 8.2 to 16.8).
Conclusions
High-impact VCT strategies are urgently needed to maximise HIV prevention and access to care in Africa. VCT at the workplace offers the potential for high uptake when offered on-site and linked to basic HIV care. Convenience and accessibility appear to have critical roles in the acceptability of community-based VCT.
Editors' Summary
Background.
Since the first case of AIDS (acquired immunodeficiency syndrome) was reported 25 years ago, AIDS has become a major worldwide epidemic, with 3 million people dying from it in 2005. AIDS is caused by the human immunodeficiency virus (HIV), which is usually spread through unprotected sex with an infected partner. HIV damages the immune system, leaving infected individuals unable to fight off other viruses and bacteria. HIV infections can be treated with drugs know as “antiretrovirals,” and in an effort to deal with the global epidemic, world leaders have committed themselves to providing universal access to these drugs for everyone who needs them by 2010. Unfortunately, although access to antiretrovirals is rapidly increasing, so is the number of people infected with HIV. Last year, there were about 5 million new HIV infections, suggesting that more emphasis on prevention will be needed to halt or reverse the spread of HIV and AIDS. An important part of prevention is testing for HIV infection, but globally only 10% of people who need testing can access it. And even where such services are available, few people use them because of the stigma attached to HIV infection and fear of discrimination.
Why Was This Study Done?
There is limited understanding about the factors that determine whether an individual will decide to have an HIV test. Yet, to reduce HIV spread, as many people at risk of infection must be tested as possible. Previous studies on VCT—a combination of voluntary testing and counseling about the implications of HIV infection and how to avoid transmitting the virus—have indicated that the convenience of getting the test, whether the test is directly offered, and the attitude of staff supplying it are all very important. In this study, the researchers asked whether providing VCT in the workplace could improve the “uptake” of HIV testing in Africa, where the HIV/AIDS epidemic is most widespread.
What Did the Researchers Do and Find?
The researchers identified businesses with occupational health clinics in Zimbabwe, a country where 25% of adults carry HIV, and divided them into two “intervention” groups. Employees at half the businesses were offered “on-site VCT”—pre-test counseling followed by same-day on-site rapid testing, results, and post-test counseling. Employees at the other businesses had the same pre-test counseling but were offered a voucher for an HIV test at an off-site testing center and a later appointment to discuss the results—so-called off-site VCT. Everyone had the same access to limited HIV care should they need it. Although half of the employees at the on-site VCT businesses took up the option of HIV testing, only a fifth of employees at the off-site VCT businesses accepted vouchers for testing, and only one in five of these people actually used their voucher. This means that on-site VCT resulted in about 12 times as many HIV tests as off-site VCT. In both interventions, most of the people who accepted testing did so soon after entering the study and very few people were tested more than once. Finally, people 25 years old or younger, manual workers, and single people were most likely to accept testing in both interventions.
What Do These Findings Mean?
These results suggest that on-site VCT in the workplace might be one way to improve uptake of HIV testing in Africa from its current low level and that providing VCT intermittently might be as effective as continuous provision. Importantly, say the researchers, the results of their study show that a relatively minor change in accessibility to testing can translate into a major difference in test uptake. This may hold true in non-occupational settings. However, these observations need to be repeated in more businesses and other settings, including those where there is no linked HIV care, before they can be generalized. Also, this study reports on the acceptability of this approach to providing VCT, but not on its impact on HIV prevention. As such the results do not indicate whether workplace VCT prevents HIV spread as effectively as other ways of delivering VCT. This will require research investigating how HIV incidence among HIV-negative employees and the partners of HIV-positive employees are affected by different VCT strategies.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030238.
• United States National Institute of Allergy and Infectious Diseases factsheet on HIV infection and AIDS
• United States Department of Health and Human Services information on HIV/AIDS treatment, prevention, and research
• US Centers for Disease Control and Prevention information on HIV/AIDS
• UNAIDS (Joint United Nations Programme on HIV/AIDS) information on political issues related to the HIV/AIDS epidemic and the 2004 UNAIDS/World Health Organization policy statement on HIV testing
•  Aidsmap: information on HIV and AIDS provided by the charity NAM, which includes the latest scientific and political news
• MedlinePlus encyclopedia entry on HIV/AIDS
Voluntary counseling and testing for HIV has the potential for high uptake when it is offered on-site at the workplace and linked to basic HIV care.
doi:10.1371/journal.pmed.0030238
PMCID: PMC1483908  PMID: 16796402
18.  A Policy Analysis of the implementation of a Reproductive Health Vouchers Program in Kenya 
BMC Public Health  2012;12:540.
Background
Innovative financing strategies such as those that integrate supply and demand elements like the output-based approach (OBA) have been implemented to reduce financial barriers to maternal health services. The Kenyan government with support from the German Development Bank (KfW) implemented an OBA voucher program to subsidize priority reproductive health services. Little evidence exists on the experience of implementing such programs in different settings. We describe the implementation process of the Kenyan OBA program and draw implications for scale up.
Methods
Policy analysis using document review and qualitative data from 10 in-depth interviews with facility in-charges and 18 with service providers from the contracted facilities, local administration, health and field managers in Kitui, Kiambu and Kisumu districts as well as Korogocho and Viwandani slums in Nairobi.
Results
The OBA implementation process was designed in phases providing an opportunity for learning and adapting the lessons to local settings; the design consisted of five components: a defined benefit package, contracting and quality assurance; marketing and distribution of vouchers and claims processing and reimbursement. Key implementation challenges included limited feedback to providers on the outcomes of quality assurance and accreditation and budgetary constraints that limited effective marketing leading to inadequate information to clients on the benefit package. Claims processing and reimbursement was sophisticated but required adherence to time consuming procedures and in some cases private providers complained of low reimbursement rates for services provided.
Conclusions
OBA voucher schemes can be implemented successfully in similar settings. For effective scale up, strong partnership will be required between the public and private entities. The government’s role is key and should include provision of adequate funding, stewardship and looking for opportunities to utilize existing platforms to scale up such strategies.
doi:10.1186/1471-2458-12-540
PMCID: PMC3490771  PMID: 22823923
Output-based approach; Reproductive health; Vouchers; Maternal health; Safe motherhood; Family planning; Policy analysis
19.  A qualitative study of the views of patients with long-term conditions on family doctors in Hong Kong 
BMC Family Practice  2010;11:46.
Background
Primary care based management of long-term conditions (LTCs) is high on the international healthcare agenda, including the Asia-Pacific region. Hong Kong has a 'mixed economy' healthcare system with both public and private sectors with a range of types of primary care doctors. Recent Hong Kong Government policy aims to enhance the management of LTCs in primary care possibly based on a 'family doctor' model. Patients' views on this are not well documented and the aim of the present study was to explore the views of patients with LTCs on family doctors in Hong Kong.
Methods
The views of patients (with a variety of LTCs) on family doctors in Hong Kong were explored. Two groups of participants were interviewed; a) those who considered themselves as having a family doctor, b) those who considered themselves as not having a family doctor (either with a regular primary care doctor but not a family doctor or with no regular primary care doctor). In-depth individual semi-structured interviews were carried out with 28 participants (10 with a family doctor, 10 with a regular doctor, and 8 with no regular doctor) and analysed using the constant comparative method.
Results
Participants who did not have a family doctor were familiar with the concept but regarded it as a 'luxury item' for the rich within the private healthcare system. Those with a regular family doctor (all private) regarded having one as important to their and their family's health. Participants in both groups felt that as well as the more usual family medicine specialist or general practitioner, traditional Chinese medicine practitioners also had the potential to be family doctors. However most participants attended the public healthcare system for management of their LTCs whether they had a family doctor or not. Cost, perceived need, quality, trust, and choice were all barriers to the use of family doctors for the management of their LTCs.
Conclusions
Important barriers to the adoption of a 'family doctor' model of management of LTCs exist in Hong Kong. Effective policy implementation seems unlikely unless these complex barriers are addressed.
doi:10.1186/1471-2296-11-46
PMCID: PMC2889885  PMID: 20525340
20.  Measuring fragmentation of ambulatory care in a tripartite healthcare system 
Background
Hong Kong has a tripartite healthcare system, where western medicine provided in both public and private sectors coexist with Chinese medicine practice. The purpose of this study is to measure fragmentation of ambulatory care experienced by the non-institutionalized population aged 15 and over in such a tripartite system, thus shed light on the ongoing primary care reform.
Methods
This is a cross-sectional secondary data analysis using the Thematic Household Survey, which was conducted by the Hong Kong Census and Statistics Department during November 2009 to February 2010 to collect territory-wide health-related information. Among 18,226 individuals with two or more ambulatory visits during the past 12 months before interview, we grouped each visit into one of the three care segments—public western, private western and Chinese medicine. Two individual-level measures were used to quantify longitudinal fragmentation of care across segments over the one-year period: Most Frequent Provider Continuity Index (MFPC) and Fragmentation of Care Index (FCI). Both are analyzed for distribution and subgroup comparison. A Tobit model was used to further examine the determinants of fragmentation.
Results
More than a quarter of individuals sought care in two or all three segments, with an average MFPC of 65% and FCI of 0.528. Being older, female, married, unemployed, uninsured, or born in mainland China, with lower education, lower income, higher number of chronic conditions or poorer health were found to have experienced higher fragmentation of care. We also found that, fragmentation of care increased with the total number of ambulatory care visits and it varied significantly depending on what segment the individual chose to visit most frequently—those chose private western clinics had lower FCI, compared with those chose public western or Chinese medicine as the most frequently visited segment.
Conclusions
Even measured at healthcare segment level, people in Hong Kong experienced modest fragmentation of care. Individuals’ health beliefs—as a result of the persistent habitual tendency and latitude incentivized by the system—may be behind the fragmented care we saw. Efforts are needed to alter health beliefs, targeting subgroups of vulnerable population, and create environments that promote better coordinated primary care.
doi:10.1186/1472-6963-13-176
PMCID: PMC3660280  PMID: 23672644
Fragmentation; Continuity of care; Ambulatory care; Chinese medicine; Primary care
21.  Costs and effects of the Tanzanian national voucher scheme for insecticide-treated nets 
Malaria Journal  2008;7:32.
Background
The cost-effectiveness of insecticide-treated nets (ITNs) in reducing morbidity and mortality is well established. International focus has now moved on to how best to scale up coverage and what financing mechanisms might be used to achieve this. The approach in Tanzania has been to deliver a targeted subsidy for those most vulnerable to the effects of malaria while at the same time providing support to the development of the commercial ITN distribution system. In October 2004, with funds from the Global Fund to Fight AIDS Tuberculosis and Malaria, the government launched the Tanzania National Voucher Scheme (TNVS), a nationwide discounted voucher scheme for ITNs for pregnant women and their infants. This paper analyses the costs and effects of the scheme and compares it with other approaches to distribution.
Methods
Economic costs were estimated using the ingredients approach whereby all resources required in the delivery of the intervention (including the user contribution) are quantified and valued. Effects were measured in terms of number of vouchers used (and therefore nets delivered) and treated nets years. Estimates were also made for the cost per malaria case and death averted.
Results and Conclusion
The total financial cost of the programme represents around 5% of the Ministry of Health's total budget. The average economic cost of delivering an ITN using the voucher scheme, including the user contribution, was $7.57. The cost-effectiveness results are within the benchmarks set by other malaria prevention studies. The Government of Tanzania's approach to scaling up ITNs uses both the public and private sectors in order to achieve and sustain the level of coverage required to meet the Abuja targets. The results presented here suggest that the TNVS is a cost-effective strategy for delivering subsidized ITNs to targeted vulnerable groups.
doi:10.1186/1475-2875-7-32
PMCID: PMC2279140  PMID: 18279509
22.  Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review 
Background
Demand-side financing, where funds for specific services are channelled through, or to, prospective users, is now employed in health and education sectors in many low- and middle-income countries. This systematic review aimed to critically examine the evidence on application of this approach to promote maternal health in these settings. Five modes were considered: unconditional cash transfers, conditional cash transfers, short-term payments to offset costs of accessing maternity services, vouchers for maternity services, and vouchers for merit goods. We sought to assess the effects of these interventions on utilisation of maternity services and on maternal health outcomes and infant health, the situation of underprivileged women and the healthcare system.
Methods
The protocol aimed for collection and synthesis of a broad range of evidence from quantitative, qualitative and economic studies. Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites. Studies were included if they examined demand-side financing interventions to increase consumption of services or goods intended to impact on maternal health, and met relevant quality criteria. Quality assessment, data extraction and analysis used Joanna Briggs Institute standardised tools and software. Outcomes of interest included maternal and infant mortality and morbidity, service utilisation, factors required for successful implementation, recipient and provider experiences, ethical issues, and cost-effectiveness. Findings on Effectiveness, Feasibility, Appropriateness and Meaningfulness were presented by narrative synthesis.
Results
Thirty-three quantitative studies, 46 qualitative studies, and four economic studies from 17 countries met the inclusion criteria. Evidence on unconditional cash transfers was scanty. Other demand-side financing modes were found to increase utilisation of maternal healthcare in the index pregnancy or uptake of related merit goods. Evidence of effects on maternal and infant mortality and morbidity outcomes was insufficient. Important implementation aspects include targeting and eligibility criteria, monitoring, respectful treatment of beneficiaries, suitable incentives for providers, quality of care and affordable referral systems.
Conclusions
Demand-side financing schemes can increase utilisation of maternity services, but attention must be paid to supply-side conditions, the fine-grain of implementation and sustainability. Comparative studies and research on health impact and cost-effectiveness are required.
doi:10.1186/1471-2393-14-30
PMCID: PMC3897964  PMID: 24438560
Demand-side financing; Maternal health; Vouchers; Cash transfers; Narrative synthesis; Qualitative; Systematic review
23.  Can Broader Diffusion of Value-Based Insurance Design Increase Benefits from US Health Care without Increasing Costs? Evidence from a Computer Simulation Model 
PLoS Medicine  2010;7(2):e1000234.
Using a computer simulation based on US data, R. Scott Braithwaite and colleagues calculate the benefits of value-based insurance design, in which patients pay less for highly cost-effective services.
Background
Evidence suggests that cost sharing (i.e.,copayments and deductibles) decreases health expenditures but also reduces essential care. Value-based insurance design (VBID) has been proposed to encourage essential care while controlling health expenditures. Our objective was to estimate the impact of broader diffusion of VBID on US health care benefits and costs.
Methods and Findings
We used a published computer simulation of costs and life expectancy gains from US health care to estimate the impact of broader diffusion of VBID. Two scenarios were analyzed: (1) applying VBID solely to pharmacy benefits and (2) applying VBID to both pharmacy benefits and other health care services (e.g., devices). We assumed that cost sharing would be eliminated for high-value services (<$100,000 per life-year), would remain unchanged for intermediate- or unknown-value services ($100,000–$300,000 per life-year or unknown), and would be increased for low-value services (>$300,000 per life-year). All costs are provided in 2003 US dollars. Our simulation estimated that approximately 60% of health expenditures in the US are spent on low-value services, 20% are spent on intermediate-value services, and 20% are spent on high-value services. Correspondingly, the vast majority (80%) of health expenditures would have cost sharing that is impacted by VBID. With prevailing patterns of cost sharing, health care conferred 4.70 life-years at a per-capita annual expenditure of US$5,688. Broader diffusion of VBID to pharmaceuticals increased the benefit conferred by health care by 0.03 to 0.05 additional life-years, without increasing costs and without increasing out-of-pocket payments. Broader diffusion of VBID to other health care services could increase the benefit conferred by health care by 0.24 to 0.44 additional life-years, also without increasing costs and without increasing overall out-of-pocket payments. Among those without health insurance, using cost saving from VBID to subsidize insurance coverage would increase the benefit conferred by health care by 1.21 life-years, a 31% increase.
Conclusion
Broader diffusion of VBID may amplify benefits from US health care without increasing health expenditures.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
More money is spent per person on health care in the US than in any other country. US health care expenditure accounts for 16.2% of the gross domestic product and this figure is rising. Indeed, the increase in health care costs is outstripping the economy's growth rate. Consequently, US policy makers and providers of health insurance—health care in the US is largely provided by the private sector and is paid for through private health insurance or through government programs such as Medicare and Medicaid—are looking for better ways to control health expenditures. Although some health care cost reductions can be achieved by increasing efficiency, controlling the quantity of health care consumed is an essential component of strategies designed to reduce health expenditures. These strategies can target health care providers (for example, by requiring primary care physicians to provide referrals before their patients' insurance provides cover for specialist care) or can target consumers, often through cost sharing. Nowadays, most insurance plans include several tiers of cost sharing in which patients pay a larger proportion of the costs of expensive interventions than of cheap interventions.
Why Was This Study Done?
Cost sharing decreases health expenditure but it can also reduce demand for essential care and thus reduce the quality of care. Consequently, some experts have proposed value-based insurance design (VBID), an approach in which the amount of cost sharing is set according to the “value” of an intervention rather than its cost. The value of an intervention is defined as the ratio of the additional benefits to the additional costs of the intervention when compared to the next best alternative intervention. Under VBID, cost sharing could be waived for office visits necessary to control blood pressure in people with diabetes, which deliver high-value care, but could be increased for high-tech scans for dementia, which deliver low-value care. VBID has been adopted by several private health insurance schemes and its core principal is endorsed by US policy makers. However, it is unclear whether wider use of VBID is warranted. In this study, the researchers use a computer simulation of the US health care system to estimate the impact of broader diffusion of VBID on US health care benefits and costs.
What Did the Researchers Do and Find?
The researchers used their computer simulation to estimate the impact of applying VBID to cost sharing for drugs alone and to cost sharing for drugs, procedures, and other health care services for one million hypothetical US patients. In their simulation, the researchers eliminated cost sharing for services that cost less than US$100,000 per life-year gained (high-value services) and increased cost-sharing for services that cost more than US$300,000 per life-year gained (low-value services); cost-sharing remained unchanged for intermediate- or unknown-value services. With the current pattern of cost sharing, 60% of health expenditure is spent on low-value services and health care increases life expectancy by 4.70 years for an annual per person expenditure of US$5,688, the researchers report. With widespread application of VBID to cost sharing for drugs alone, health care increased life expectancy by an additional 0.03 to 0.05 years without increasing costs. With widespread application of VBID to cost sharing for other health care services, health care increased life expectancy by a further 0.24 to 0.44 years without additional costs. Finally, if the costs saved by applying VBID were used to subsidize insurance for the 15% of the US population currently without health insurance, the benefit conferred by health care among these people would increase by 1.21 life-years.
What Do These Findings Mean?
The findings of this study depend on the many assumptions included in the computer simulation, which, although complex, is a greatly simplified representation of the US health care system. Nevertheless, these findings suggest that if VBID were used more widely within the US health care system to encourage the use of high-value services, it might be possible to amplify the benefits from US health care without increasing health expenditures. Importantly, the money saved by VBID could be used to help fund universal insurance, a central aim of US health care reform. More research is needed, however, to determine the value of various health care interventions and to investigate whether other ways of linking value to cost sharing might yield even better gains in life expectancy at little or no additional cost.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000234.
Wikipedia has a page on health care in the United States (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
Families USA works to promote high-quality affordable health care for all Americans and provides information about all aspects of US health care and about US health care reforms
The US Centers for Medicare and Medicaid provides information on the major government health insurance programs and on US national health expenditure statistics
doi:10.1371/journal.pmed.1000234
PMCID: PMC2821897  PMID: 20169114
24.  United States Private-Sector Physicians and Pharmaceutical Contract Research: A Qualitative Study 
PLoS Medicine  2012;9(7):e1001271.
Jill Fisher and Corey Kalbaugh describe their findings from a qualitative research study evaluating the motivations of private-sector physicians conducting contract research for the pharmaceutical industry.
Background
There have been dramatic increases over the past 20 years in the number of nonacademic, private-sector physicians who serve as principal investigators on US clinical trials sponsored by the pharmaceutical industry. However, there has been little research on the implications of these investigators' role in clinical investigation. Our objective was to study private-sector clinics involved in US pharmaceutical clinical trials to understand the contract research arrangements supporting drug development, and specifically how private-sector physicians engaged in contract research describe their professional identities.
Methods and Findings
We conducted a qualitative study in 2003–2004 combining observation at 25 private-sector research organizations in the southwestern United States and 63 semi-structured interviews with physicians, research staff, and research participants at those clinics. We used grounded theory to analyze and interpret our data. The 11 private-sector physicians who participated in our study reported becoming principal investigators on industry clinical trials primarily because contract research provides an additional revenue stream. The physicians reported that they saw themselves as trial practitioners and as businesspeople rather than as scientists or researchers.
Conclusions
Our findings suggest that in addition to having financial motivation to participate in contract research, these US private-sector physicians have a professional identity aligned with an industry-based approach to research ethics. The generalizability of these findings and whether they have changed in the intervening years should be addressed in future studies.
Please see later in the article for the Editors' Summary.
Editors' Summary
Background
Before a new drug can be used routinely by physicians, it must be investigated in clinical trials—studies that test the drug's safety and effectiveness in people. In the past, clinical trials were usually undertaken in academic medical centers (institutes where physicians provide clinical care, do research, and teach), but increasingly, clinical trials are being conducted in the private sector as part of a growing contract research system. In the US, for example, most clinical trials completed in the 1980s took place in academic medical centers, but nowadays, more than 70% of trials are conducted by nonacademic (community) physicians working under contract to pharmaceutical companies. The number of private-sector nonacademic physicians serving as principal investigators (PIs) for US clinical trials (the PI takes direct responsibility for completion of the trial) increased from 4,000 in 1990 to 20,250 in 2010, and research contracts for clinical trials are now worth more than USṩ11 billion annually.
Why Was This Study Done?
To date, there has been little research on the implications of this change in the conduct of clinical trials. Academic PIs are often involved in both laboratory and clinical research and are therefore likely to identify closely with the science of trials. By contrast, nonacademic PIs may see clinical trials more as a business opportunity—pharmaceutical contract research is profitable to US physicians because they get paid for every step of the trial process. As a result, pharmaceutical companies may now have more control over clinical trial data and more opportunities to suppress negative data through selective publication of study results than previously. In this qualitative study, the researchers explore the outsourcing of clinical trials to private-sector research clinics through observations of, and in-depth interviews with, physicians and other research staff involved in the US clinical trials industry. A qualitative study collects non-quantitative data such as how physicians feel about doing contract research and about their responsibilities to their patients.
What Did the Researchers Do and Find?
Between October 2003 and September 2004, the researchers observed the interactions between PIs, trial coordinators (individuals who undertake many of the trial activities such as blood collection), and trial participants at 25 US research organizations in the southwestern US and interviewed 63 informants (including 12 PIs) about the trials they were involved in and their reasons for becoming involved. The researchers found that private-sector physicians became PIs on industry-sponsored clinical trials primarily because contract research was financially lucrative. The physicians perceived their roles in terms of business rather than science and claimed that they offered something to the pharmaceutical industry that academics do not—the ability to carry out a diverse range of trials quickly and effectively, regardless of their medical specialty. Finally, the physicians saw their primary ethical responsibility as providing accurate data to the companies that hired them and did not explicitly refer to their ethical responsibility to trial participants. One possible reason for this shift in ethical concerns is the belief among private-sector physicians that pharmaceutical companies must be making scientifically and ethically sound decisions when designing trials because of the amount of money they invest in them.
What Do These Findings Mean?
These findings suggest that private-sector physicians participate as PIs in pharmaceutical clinical trials primarily for financial reasons and see themselves as trial practitioners and businesspeople rather than as scientists. The accuracy of these findings is likely to be limited by the small number of PIs interviewed and by the time that has elapsed since the researchers collected their qualitative data. Moreover, these findings may not be generalizable to other regions of the US or to other countries. Nevertheless, they have potentially troubling implications for drug development. By hiring private-sector physicians who see themselves as involved more with the business than the science of contract research, pharmaceutical companies may be able to exert more control over the conduct of clinical trials and the publication of trial results than previously. Compared to the traditional investigatorinitiated system of clinical research, this new system of contract research means that clinical trials now lack the independence that is at the heart of best science practices, a development that casts doubt on the robustness of the knowledge being produced about the safety and effectiveness of new drugs.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001271.
The ClinicalTrials.gov website is a searchable register of federally and privately supported clinical trials in the US; it provides information about all aspects of clinical trials
The US National Institutes of Health provides information about clinical trials, including personal stories about clinical trials from patients and researchers
The UK National Health Service Choices website has information for patients about clinical trials and medical research, including personal stories about participating in clinical trials
The UK Medical Research Council Clinical Trials Unit also provides information for patients about clinical trials and links to information on clinical trials provided by other organizations
MedlinePlus has links to further resources on clinical trials (in English and Spanish)
doi:10.1371/journal.pmed.1001271
PMCID: PMC3404112  PMID: 22911055
25.  Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia 
Background
In many developing countries, the maternal mortality ratio remains high with huge poor-rich inequalities. Programmes aimed at improving maternal health and preventing maternal mortality often fail to reach poor women. Vouchers in health and Health Equity Funds (HEFs) constitute a financial mechanism to improve access to priority health services for the poor. We assess their effectiveness in improving access to skilled birth attendants for poor women in three rural health districts in Cambodia and draw lessons for further improvement and scaling-up.
Methods
Data on utilisation of voucher and HEF schemes and on deliveries in public health facilities between 2006 and 2008 were extracted from the available database, reports and the routine health information system. Qualitative data were collected through focus group discussions and key informant interviews. We examined the trend of facility deliveries between 2006 and 2008 in the three health districts and compared this with the situation in other rural districts without voucher and HEF schemes. An operational analysis of the voucher scheme was carried out to assess its effectiveness at different stages of operation.
Results
Facility deliveries increased sharply from 16.3% of the expected number of births in 2006 to 44.9% in 2008 after the introduction of voucher and HEF schemes, not only for voucher and HEF beneficiaries, but also for self-paid deliveries. The increase was much more substantial than in comparable districts lacking voucher and HEF schemes. In 2008, voucher and HEF beneficiaries accounted for 40.6% of the expected number of births among the poor. We also outline several limitations of the voucher scheme.
Conclusions
Vouchers plus HEFs, if carefully designed and implemented, have a strong potential for reducing financial barriers and hence improving access to skilled birth attendants for poor women. To achieve their full potential, vouchers and HEFs require other interventions to ensure the supply of sufficient quality maternity services and to address other non-financial barriers to demand. If these conditions are met, voucher and HEF schemes can be further scaled up under close monitoring and evaluation.
doi:10.1186/1471-2393-10-1
PMCID: PMC2820432  PMID: 20059767

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