UC Berkeley

Maternal mortality has been one of the most daunting public health problems facing developing countries for several decades. The average lifetime risk of maternal death in least developed countries is 1 in 22 compared with 1 in 8000 in industrialized countries. Such vast regional differences demonstrate how available and accessible resources can completely change the picture. Even in low-resource settings, it has been shown that basic district health systems can deliver the services needed to save women's lives. But women face many barriers to accessing care including distance, transportation, cost, perceived poor quality or actual poor quality. One mechanism that researchers and policy makers have been experimenting with to address several of these barriers is a voucher. Within a health voucher program, a woman can purchase a voucher for a fraction of the cost of services or receive it for free and redeem it an accredited health facilities (public or private) for specific services. Facilities are reimbursed for the care they deliver through government or development aid. Voucher programs aim to give patients the economic power to demand high-quality healthcare, to target aid to high-risk or low-income patients for critical services and to increase utilization rates within these populations.

Funders and policymakers have already shown support for this concept but more evidence is needed in order to evaluate if these programs should be taken to greater scale. This dissertation aims to address gaps in evidence and to work towards building stronger and more evidence- based policy around maternal health vouchers.

The first component of this dissertation is a systematic review of the literature on voucher programs for health goods and services in developing countries. The review aims to assess whether the evidence for voucher programs thus far has shown that they are achieving their objectives and examines contextual factors associated with program success. The second component is an evaluation of how a reproductive health voucher programs impacts the job satisfaction of management and frontline health care providers in Uganda. The third component is a qualitative assessment of the experiences of women who are eligible to receive a reproductive health voucher in Cambodia and assesses facilitative and inhibitive factors that affect voucher use.

As a result of this dissertation experience, next steps for improved policymaking around vouchers have been identified and include the need to focus efforts on evaluating if policy makers should use health voucher to support broader health system strengthening and how program implementers can use the experiences of beneficiaries (providers and patients) to tailor voucher programs to the local context while maintaining program fidelity.