Voucher Users Research Articles

European priority review vouchers for neglected disease product development

IntroductionNeglected diseases are a significant global health challenge. Encouraging the development of therapeutics and vaccines for these diseases would address an important unmet medical need. We propose a priority review...

Experience of a demand-side subsidy scheme for residential long-term care: perspectives of elderly and their carers

BackgroundVouchers, which are demand-side subsidies to targeted groups, are a type of consumer-led near-cash social transfer for specified benefits that have been used in education, health and other sectors. To provide better access to residential care services and an additional choice for elderly people in need, a novel means-tested residential care service voucher has been introduced in Hong Kong for elderly people to purchase places in the private sector to enable consumer-directed care. The objectives of this paper are to analyze the perspectives of voucher users and their carers toward the voucher scheme and to identify key elements in the design that will contribute to meeting the scheme’s objectives.MethodsAn exploratory sequential mixed method design was adopted with initial explorative qualitative data collection of the perspectives of elderly people and their carers (Phase 1), which informed the design of the subsequent questionnaire survey (Phase 2). Thirty carers in 5 focus groups and 20 individual interviews with elderly people were conducted between April and May 2018. A total of 401 respondents (373 carers and 28 elderly people) completed the survey questionnaire. Findings from both phases were integrated both narratively and via a joint display.ResultsFive key themes summarized the features in two main elements of the design and implementation of the voucher scheme: awareness, meaning that inadequate knowledge and understanding of voucher schemes hinder participation; service needs and types, indicating that the urgent need for residential care services is the key reason for participation; shared responsibility, meaning that a high copayment level discourages participation; choice and flexibility, reflecting appreciation of the additional choices provided by voucher schemes although the availability of residential care beds limits choices; and service quality, indicating mixed perceptions of service quality and the impact of the voucher scheme. Voucher users believe that the voucher scheme is more helpful for relieving the financial burden (98.7%), reducing carers’ stress (97.0%) and reducing the waiting time for subsidized homes for elderly people (89.0%) than for increasing choice and flexibility (78.1%) and improving service quality (62.1%).ConclusionsThis study demonstrates how the design of a voucher scheme affects its take-up by targeted beneficiaries. When a voucher scheme is implemented in a long-term care system, it must consider the congruence with existing policies in long-term care provision and financing. The voucher scheme in Hong Kong has been able to generate the utilization of nonsubsidized places in homes for elderly people that were underutilized, but its effectiveness is limited by inadequate knowledge and understanding of the voucher scheme and the availability of residential care places. Giving the purchasing power and choice of providers to beneficiaries has the potential to enhance the quality of services, which will contribute to meeting the objectives. The study findings carry significant implications for long-term care policies and provide insights into the key features of the voucher scheme for residential care services and how to best design and implement a voucher scheme for elderly people in the context of policy objectives and a long-term care policy.

Changes in utilisation of optometry services with a non-targeted publicly-funded health care voucher system

ABSTRACT Clinical relevance Understanding the impact of a health care voucher scheme and service access barriers could facilitate optometry service promotion to the older population. Background A voucher is one strategy to improve the utilisation of the different health care services available in the private sector. This study aims to explore how a health care voucher system for older people impacts utilisation of optometry services from the perspective of service users and service providers. Methods People aged 65 years or above were recruited to fill in a structured questionnaire studying the usage characteristics and access barriers of optometry services and the health care voucher. Views from the optometrists about the voucher scheme were collected by questionnaire. Results A total of 1156 valid questionnaires from eligible voucher users was collected. Results showed that 53.7% (621/1156) of participants had used optometry services within the past 2 years. Lack of familiarity with services provided, professional fees, and prices of spectacles were the main barriers to using optometry services. Of those participants who had used the voucher for optometry services previously, 80.4% (284/353) had an eye examination in the past 2 years. Among 389 optometrists who participated in the study, over 80% agreed that the voucher scheme improved awareness of major eye conditions and access to prescription spectacles when necessary. Conclusion The health care voucher for older people improved access to optometry services. Access could be further improved by increasing price transparency of professional services and prescription spectacles. Responses from optometry service providers supported the view that the voucher scheme improved access to, and utilisation of, preventive care services.

Mind the (Participation) Gap: Vouchers, Voting, and Visibility

This study exploits the introduction of a new type of public financing of elections—campaign finance vouchers—to estimate the effects of neighborhood-level political cross-pressure on citizens’ decisions to participate in low-cost political activities which vary in their publicness: voting (private) and vouchering (public). Does proximity to ideologically divergent neighbors affect one’s use of publicly disclosed campaign finance vouchers? We find that cross-pressured individuals are slightly more likely to use a campaign finance voucher than similarly situated individuals who are ideologically typical for their precinct. We also find evidence that precinct-level cross-pressure does not drive voucher users to shade their voucher donations toward candidates who are ideologically closer the precinct mean. While our study is limited to a relatively liberal city (Seattle), our results replicated across two election cycles in that city, and our methods can easily be extended to future elections. Finally, our findings raise questions about the empirical assumptions that have shaped the development of campaign finance jurisprudence since 1976.

Dollars and Sense: Calculating the Fiscal Effects of the Louisiana Scholarship Program

ABSTRACT After recent experimental evidence suggesting that private school students using the Louisiana Scholarship Program (LSP) performed worse than their public school peers in math, some legislators discussed cutting the program as a way to reduce state education expenditures in Louisiana, spinning it as a way to save taxpayer money. While cutting the program would save money by reducing voucher expenditures, it would also increase state education costs by displacing students from private schools into district schools. This study provides a range of estimates of the short-run net fiscal effect of canceling the LSP. In our most plausible scenario, we find a negative impact on the state budget unless at least 21% of current voucher users stayed in their private schools and paid tuition without the benefit of the voucher. In the projections that assume 10% of students remain in private schools without the program, eliminating the LSP would increase state education expenditures by approximately $6.3 million the first year, or roughly $900 per displaced student.

Diversifying the Donor Pool: How Did Seattle's Democracy Voucher Program Reshape Participation in Municipal Campaign Finance?

In this article, we evaluate whether an innovative new campaign finance program in Seattle, Washington, shifted the composition of campaign donors in local elections. In 2015, voters in Seattle approved the creation of the Democracy Voucher program with the intent of broadening representation in the campaign finance system and expanding participation from marginalized communities. Every registered voter in Seattle was provided with four 25-dollar vouchers that they could, in turn, assign to the local candidate(s) of their choice. Through an analysis of the inaugural implementation of the program in 2017, we investigate whether this innovative public financing system increased participation, broadened involvement from underrepresented groups, and led to a donor pool that was more representative of the electorate. Compared to cash donors in the municipal election, we report that voucher users are less likely to be high-income and more likely to come from poor neighborhoods. While older residents are overrepresented among voucher users, there is little difference in the racial composition of cash donors and voucher users. Our analysis confirms that the Democracy Voucher program successfully moved the donor pool in a more egalitarian direction, although it remains demographically unrepresentative of the electorate. The lessons from Seattle's inaugural implementation offer key insights for other municipalities considering public financing policies, and these lessons have the potential to reshape the national policy debate about the influence of political money.

Assessment of modern contraceptives continuation, switching and discontinuation among clients in Pakistan: study protocol of 24-months post family planning voucher intervention follow up

BackgroundPakistan has the second highest fertility rate in South Asia and its increasing population growth presents a significant challenge for country’s path to progress and development. Modern contraceptive methods only account for a slow-rising 26% of use in Pakistan which is further lowest in the underserved areas (< 20%), with a high unmet need for family planning (20%). The David and Lucile Packard Foundation USA and Pakistan funded two operational research projects from 2012 to 2015, that employed a Demand-side Financing (DSF) approach testing the effectiveness of single and multi-purpose voucher schemes in increasing access and uptake of FP services and products among the women of two-lowest income quintiles in the Punjab province of Pakistan. The present paper presents a study protocol which intends to assess the longer term impact of these two voucher intervention programs among married women of reproductive age (MWRA) who received contraceptive services through vouchers.MethodsThis will be a mixed methods study using qualitative and quantitative approaches. A quantitative cross sectional survey will measure the contraceptive uptake among voucher users, included in the endline survey and to examine the attitudes and behaviour of women with respect to contraceptive continuation, switching and discontinuation 24 months post intervention in two districts of Chakwal and Faisalabad in Punjab province of Pakistan. Qualitative in-depth interviews will be conducted with FP service providers operating in intervention areas and with key policy makers in the public sector to examine and document the service provider perspective on sustainability on contraceptive practices and behaviour in the post project closure period within the intervention areas.DiscussionGlobally, there is almost negligible direct evidence on the assessment of longer-term impact of a demand-side financing programs using free or subsidized vouchers for family planning services especially during post-intervention period or when donor money runs out. The findings of this study will help fill the knowledge gap in the context of sustainability issues post-intervention and will provide information to policy makers to develop and plan contraceptive services in the target area to sustain the positive behaviour change in the population.

Prioritizing Choice: Perceptions of Neighborhood Social Cohesion for Residents in Subsidized Housing

ABSTRACTMany families living in poverty rely on housing subsidies. Housing subsidies restrict the housing stock and neighborhood choices for families living in poverty. Fortunately neighborhood social cohesion can protect families from many of the deleterious consequences associated with living in a low-income neighborhood. This study uses panel data from the Annie E. Casey Foundation's Making Connections initiative to test the role of public housing types on perceptions of neighborhood social cohesion. The probability sample used in the study consists of 2,470 households living in low-income neighborhoods in ten cities in the United States. Results show that public housing residents, both housing choice voucher users and non-housing choice voucher users, on average, report lower neighborhood social cohesion than their non-public housing neighbors. Results also show that moving to a new neighborhood consistently predicts improved neighborhood social cohesion while moving to public housing predicts declines in perceived neighborhood social cohesion. Choice in where one lives seems to play an important and positive role in perceptions of neighborhood social cohesion. Based on these data, it is suggested that policy makers and housing providers prioritize choice in the development and delivery of public housing.

The Fiscal Effect of Eliminating the Louisiana Scholarship Program on State Education Expenditures

Eliminating the Louisiana Scholarship Program has been proposed as a way to reduce state education expenditures for the upcoming fiscal year. Drawing upon Louisiana’s education funding formulas, we determine that the overall effect of removing the program will increase state education expenditures. It is true that the state would avoid $41.6 million of spending if the voucher program is eliminated. However, each current voucher student who returns to a public school increases the local district’s necessary education expenditures without increasing the local tax revenue for schools, obligating the state to provide increased funding to the district. While our results depend on which assumptions we use, our analysis generally indicates the net effect of eliminating the program is an increase in state funding to local districts. In particular, we find evidence of the need for additional funding in nearly all scenarios in which the program is eliminated unless at least 13.52% of current voucher users stay in private schools and pay tuition out of pocket or through other private means.

Increasing Contraceptive Access for Hard-to-Reach Populations With Vouchers and Social Franchising in Uganda

From 2001 to 2011, modern contraceptive prevalence in Uganda increased from 18% to 26%. However, modern method use, in particular use of long-acting reversible contraceptives (LARCs) and permanent methods (PMs), remained low. In the 2011 Uganda Demographic and Health Survey, only 1 of 5 married women used a LARC or PM even though 34% indicated an unmet need for contraception. Between 2011 and 2014, a social franchise and family planning voucher program, supporting 400 private facilities to provide family planning counseling and broaden contraceptive choice by adding LARCs and PMs to the service mix, offered a voucher to enable poor women to access family planning services at franchised facilities. This study analyzes service trends and voucher client demographics and estimates the contribution of the program to increasing contraceptive prevalence in Uganda, using the Impact 2 model developed by Marie Stopes International. Between March 2011 and December 2014, 330,826 women received a family planning service using the voucher, of which 70% of voucher clients chose an implant and 25% chose an intrauterine device. The median age of voucher users was 28 years; 79% had no education or only a primary education; and 48% reported they were unemployed or a housewife. We estimated that by 2014, 280,000 of the approximately 8,600,000 women of reproductive age in Uganda were using a contraceptive method provided by the program and that 120,000 of the clients were "additional users" of contraception, contributing 1.4 percentage points to the national modern contraceptive prevalence rate. The combination of family planning vouchers and a franchise-based quality improvement initiative can leverage existing private health infrastructure to substantially expand family planning access and choice for disadvantaged populations and potentially improve contraceptive prevalence when scaled nationally.

Taking Stock and Moving Forward: Lessons From Two Plus Decades of Research on the Milwaukee Parental Choice Program

ABSTRACTIn this article we review the substantial literature on the Milwaukee Parental Choice Program (MPCP), the U.S.’s oldest and largest urban school voucher program, and use the review to propose an agenda for second generation school voucher research. We review research on student-level impacts, public school response, parental decision-making, fiscal impacts, organizational churn, and the larger public policy issues resulting from Milwaukee’s voucher policy. We conclude that the balance of literature on the MPCP shows limited positive effects for voucher users, positive fiscal impacts for taxpayers, substantial numbers of school closures, and various externalities that need to be better understood given the program’s size and prominence. Given this, we suggest a future research agenda focused on the question of how to make voucher policies as successful as possible.

Understanding Consumption Behavior: Evidence from Consumers' Reaction to Shopping Vouchers

This paper advances our understanding of consumption behavior using the 2009 Taiwan Shopping Voucher Program. This program was universal and well publicized, and its payment to each individual was medium-sized. Based on survey data, it is found that the marginal propensity to consume is about one quarter, which is comparable to findings obtained by previous studies on consumers' response to fiscal stimulus payments. Further, vendors' discounts for voucher users played a significant role in boosting the effectiveness of the program. (JEL D12, E21, E62)

Evaluating School Vouchers: Evidence from a Within-Study Comparison

Background. Randomized Controlled Trials are the “gold-standard” for estimating causal impacts of education programs. They are not always feasible, however, and may not generalize to the population of interest. Generally, researchers cannot measure selection bias in quasi-experimental estimates, leaving us uncertain about the true program impact. Objective. This study assesses the performance of propensity score matching, kernel matching, and multivariate regression in replicating the experimental results of a District of Columbia school voucher evaluation. Research Design. We assess whether nonexperimental methods can replicate experimental results among two samples: the experimental sample, in which treated and nontreated students are similar in terms of their eligibility status and desire to apply for the program, and a broader nonexperimental sample that includes geographically similar comparison units who did not apply for the program. Results. Nonexperimental methods more closely replicate experimental estimates when the sample is limited to program applicants. Little evidence suggests that a particular nonexperimental method performs better than other approaches. The direction of the bias in the quasi-experimental estimates tends to be positive when the sample is limited to program applicants, but negative when expanded to non-applicants. This pattern suggests that voucher program applicants are negatively selected on unmeasured characteristics but voucher users are positively selected on unmeasured factors.

Matthew Runs Amok: The Belgian Service Voucher Scheme

In response to structurally poor job prospects for the least skilled, a number of European countries have introduced measures to boost domestic services employment. No country has done so with more fervor than Belgium. Belgian consumers can use the so-called Service Vouchers to pay for a limited but high volume range of domestic services like cleaning, washing and ironing. It is probably the most heavily subsidized scheme of its kind in Europe – more than 70 per cent of the cost of services rendered to individual consumers is borne by the state. Not surprisingly, the scheme has proved tremendously popular. This contribution argues that the scheme is facing a number of particular problems and challenges. While initially many of the people employed under the scheme had experienced past unemployment spells, new recruitment has increasingly drawn on the ranks of those already in work. Furthermore, entrapment in service voucher jobs is rife, going against the purported objective of the scheme in offering a stepping stone to the regular market. Another worrying aspect is that there is some evidence of partial displacement of regular skilled workers. The principal winners are the generally highly educated, relatively well-earning service voucher users who can now outsource domestic chores at a bargain price in the regular market, gaining leisure and care time as well as getting in return more trustworthy, reliable and better quality services than would otherwise be obtainable.

Community experiences and perceptions of reproductive health vouchers in Kenya

BackgroundResearch on demand-side health care financing approaches such as output-based aid (OBA) programs have focused on evaluating the role of the programs improving such outcomes as utilization of services and quality of services with limited focus on the experiences and perceptions of the target communities. This paper examines community members’ views of the output-based aid voucher program in Kenya.MethodsA household survey was conducted in 2010 among 1,336 women aged 15-49 years living in the catchment areas of contracted health facilities in three districts participating in the voucher program (Kisumu, Kiambu and Kitui). Twenty seven focus group discussions were conducted with voucher users, non-users, opinion leaders and voucher distributors in the three districts as well as in Nairobi. Analysis of the quantitative data involved frequency distributions and cross-tabulations. Qualitative data were transcribed and analyzed by adopting framework analysis and further triangulation of themes across respondents.ResultsMajority (84%) of survey respondents had heard about the safe motherhood voucher compared to 24% and 1% that had heard about the family planning and gender-based violence recovery services (GBVRS) vouchers respectively. Similarly, 20% of the respondents had used the safe motherhood voucher compared to 2% for family planning and none for the GBVRS vouchers. From the community members’ perspectives, the voucher program is associated with improvements in access to health services for poor women, improved quality of care, and empowerment of women to make health care decisions. However, community members cited difficulties in accessing some accredited health facilities, limitations with the system of selling vouchers, lack of male involvement in women’s reproductive health issues, and poor understanding of the benefits associated with purchasing the voucher.ConclusionThe findings of this paper showed that the voucher program in Kenya is viewed by the community members as a feasible system for increasing service utilization, improving quality of care, and reducing financial barriers to accessing reproductive health services. However, the techniques of program execution such as proper information and availability of the distributors as well as local attitudes influence whether vouchers are purchased and used.

Nuclear Power Plant Emergency Preparedness: Results From an Evaluation of Michigan's Potassium Iodide Distribution Program

In 2009, the Michigan Department of Community Health (MDCH) made potassium iodide (KI), a nonprescription radio-protective drug, available by mailing vouchers redeemable at local pharmacies for KI tablets, at no cost to residents living within 10 miles of Michigan's 3 nuclear power plants (NPPs). MDCH conducted an evaluation of this program to determine Michigan's KI coverage and to assess general emergency preparedness among residents living near the NPPs. KI coverage was estimated based on redeemed voucher counts and the 2010 Census. Telephone surveys were administered to a random sample (N = 153) of residents living near Michigan's NPPs to evaluate general emergency preparedness, reasons for voucher use or nonuse, and KI knowledge. Only 5.3% of eligible residences redeemed KI vouchers. Most surveyed residents (76.5%) were aware of living near an NPP, yet 42.5% reported doing "nothing" to plan for an emergency. Almost half of surveyed voucher users did not know when to take KI or which body part KI protects. Among voucher nonusers, 48.0% were either unaware of the program or did not remember receiving a voucher. Additional efforts are needed to ensure that all residents are aware of the availability of KI and that recipients of the drug understand when and why it should be taken. Minimal emergency planning among residents living near Michigan's NPPs emphasizes the need for increased emergency preparedness and awareness. Findings are particularly salient given the March 2011 Fukushima Daiichi Nuclear Power Plant emergency in Japan.

Exploring the effectiveness of the output-based aid voucher program to increase uptake of gender-based violence recovery services in Kenya: A qualitative evaluation

BackgroundFew studies in Africa have explored in detail the ability of output-based aid (OBA) voucher programs to increase access to gender-based violence recovery (GBVR) services.MethodsA qualitative study was conducted in 2010 and involved: (i) in-depth interviews (IDIs) with health managers, service providers, voucher management agency (VMA) managers and (ii) focus group discussions (FGDs) with voucher users, voucher non-users, voucher distributors and opinion leaders drawn from five program sites in Kenya.ResultsThe findings showed promising prospects for the uptake of OBA GBVR services among target population. However, a number of factors affect the uptake of the services. These include lack of general awareness of the GBVR services vouchers, lack of understanding of the benefit package, immediate financial needs of survivors, as well as stigma and cultural beliefs that undermine reporting of cases or seeking essential medical services. Moreover, accreditation of only hospitals to offer GBVR services undermines access to the services in rural areas. Poor responsiveness from law enforcement agencies and fear of reprisal from perpetrators also undermine treatment options and access to medical services. Low provider knowledge on GBVR services and lack of supplies also affect effective provision and management of GBVR services.ConclusionsThe above findings suggest that there is a need to build the capacity of health care providers and police officers, strengthen the community strategy component of the OBA program to promote the GBVR services voucher, and conduct widespread community education programs aimed at prevention, ensuring survivors know how and where to access services and addressing stigma and cultural barriers.

Voucher Users and Revitalized Public-Housing Residents 6 Years After Displacement

Objective: A total of 6 years after displacement by a Housing Opportunities for People Everywhere (HOPE VI) project, this research examines residents who returned to the redeveloped community and residents who decided to keep their vouchers and were living in private sector housing. Respondents were compared on the following variables: application process and decision to move back, satisfaction with housing, material hardships, and perception of economic well-being. Method: The study employed a static group comparison research design. Quantitative and qualitative data were collected from 56 respondents through five focus groups. Results: Residents who moved back to the revitalized public housing were highly satisfied with their housing, had significantly fewer material hardships, and perceived their economic well-being more positively compared to residents remaining in the voucher program. Conclusions: Our results both support and expand upon previous empirical findings on the complex comparisons between voucher users and revitalized public-housing residents.

Relocation of urban poor in Chicago: HOPE VI policy outcomes

The HOPE VI program was created in 1992 as a tool for public housing authorities in the US to deconcentrate poverty in project-based public housing neighborhoods. As part of the process, thousands of public housing residents have been required to relocate. They have the option to move to temporary housing in another project unit, to leave the subsidized housing system all together, or to participate in local housing voucher programs. This study focuses on those public housing residents in Chicago who move with a housing voucher certificate. The purpose of the study is to evaluate and reveal the relocation outcomes of these voucher users, both numerically and geographically. Conditions in their origin and relocation tracts are examined using 1990 and 2000 US census data to determine if they relocated to less poor and segregated neighborhoods. Evidence shows that voucher users are moving in an outward direction away from the central city. This movement is reshaping the landscape of advantage and disadvantage in Chicago: suburbs are becoming poorer while the old neighborhoods are gentrifying. Poverty is highly concentrated in the neighborhoods chosen by most voucher recipients, but not as high as the poverty levels which existed in the old neighborhoods. Mapping relocation shows that outcomes vary geographically, demonstrating the importance for future research to address spatial and contextual differences.

Struggling to stay out of high-poverty neighborhoods: housing choice and locations in moving to opportunity's first decade

Improving locational outcomes emerged as a major policy hope for the nation's largest low-income housing program over the past two decades, but a host of supply and demand-side barriers confront rental voucher users, leading to heated debate over the importance of choice versus constraint. In this context, we examine the Moving to Opportunity experiment's first decade, using a mixed-method approach. MTO families faced major barriers in tightening markets, yet diverse housing trajectories emerged, reflecting variation in: (a) willingness to trade location – in particular, safety and avoidance of “ghetto” behavior – to get larger, better housing units after initial relocation; (b) the distribution of neighborhood types in different metro areas; and (c) circumstances that produced many involuntary moves. Access to social networks or services “left behind” in poorer neighborhoods seldom drove moving decisions. Numerous moves were brokered by rental agents who provided shortcuts to willing landlords but thereby steered participants to particular neighborhoods.