What can vouchers do for universal health coverage?

A surprising amount, actually. A voucher gives its recipient the right to access a specific health service (or health service package) at quality-assured health facilities for free. That same voucher enables the health provider to claim payment for the services they provided to the voucher-holding client. That’s why voucher programmes are often described as a demand-side subsidy with a supply-side effect.

This nifty ‘2-for-1’ characteristic means that vouchers can do a lot of good for all three key principles of universal health coverage: equity, financial protection, and quality of care. On the equity front, targeted enforcement of entitlements to free care ensure that even the most vulnerable can benefit from effective coverage. By largely eliminating out of pocket payments, vouchers also contribute to financial protection, while building the systems needed for social health insurance (SHI). Finally, vouchers contribute to quality of care by incentivizing health providers to re-structure services and invest voucher revenues in order to attract voucher clients, and by putting accreditation and quality assurance processes in place.

The tricky part is this: although vouchers don’t have to be targeted, most voucher programs do support specific groups of people to access a specific health service. So although they promote the key principles of Universal Health Coverage, they themselves are not universal. Perhaps for this reason, health financing discourse keeps relegating vouchers to the ‘pilot’ group of health financing approaches, without graduating them to the ‘policy’ group. This is a mistake. Vouchers can address very common pitfalls in standard health financing approaches for UHC, not by replacing these approaches, but by providing additional, much needed support. What’s more, vouchers do this precisely because they are targeted at specific services and/or specific groups of people. For example, vouchers can help with the following issues:

  1. A lack of attention to prevention and public health in social health insurance systems (SHI). Some fledgling insurance schemes only cover expensive inpatient care (India, Kenya, Philippines). Vouchers can provide support to such SHI schemes to ensure that important preventative health services are not left by the way-side. For example, targeted voucher programmes have been used to increase the uptake of long-acting family planning services (Pakistan, Malawi), immunization (Cambodia and Armenia), and cervical and breast cancer screening (Nicaragua, Vietnam).

  2. Exclusion of the private sector from coverage in input-based health financing systems. Vouchers provide a structure to include private sector providers in universal health coverage, thereby increasing the quantity or quality of health services available, and abolishing a two-tier system of care. In Australia, for example, vouchers are being discussed as an innovative solution to increase the uptake of services such as diabetic eye and foot care, by giving clients the choice to access care through the private sector.

  3. Building UHC from the top-down, resulting in inequitable coverage. Vouchers enable the rural or informally employed classes, who are notoriously difficult to insure, to access financial protection too.

We’ve often heard that no specific health financing strategy holds the answer to UHC. We’ve also heard more recently that achieving UHC probably requires deploying several strategies at once.

Next time you’re thinking of mixing it up, think vouchers. In the meantime, check out this article by Laura Sochas, Corinne Grainger, Anna Gorter, David Griffith, and Luke Boddam-Whetham, to find out more.

Well done, Laura! A concise

Well done, Laura! A concise overview that puts together very well the many facets of introducing vouchers in health care financing. Of course, it will not be a panacea for all the challenges surrounding sustainable and equitable financing of health care but I strongly believe it is a key move in putting the patient first - not only in the clinician's perspective, but also in the social policy perspective.

In fact, Germany's Social Health Insurance (SHI) system started with the introduction of vouchers! Up until around 20 years ago, all SHI members received every year a set of "Krankenscheine" (vouchers) that allowed them to approach any registered doctor in private practice to provide care for a quarter of a year. Details about the services rendered were documented on this voucher and then reimbursed by the Association of SHI Doctors (kassenärztliche Vereinigung).

An important aspect of the SHI system that is often overlooked is self-administration. All SHI (there are currently about 140 schemes in Germany) are owned by its members, they are not under the Ministry of Health! Members elected every five years (in so-called "social elections") a Board, which in turn selects the CEO of the SHI scheme, just like in any joint stock company. Such an element of financial oversight and democratic decision-making might be coupled with the introduction of vouchers when moving towards true equity and social protection.

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