1. COUPONS FOR CARE
A voucher-based solution to India’s child healthcare
problem

2. Child health in India – problems and
causes
57/1000 – Infant
mortality rate
50% deliveries
happen at home
44% children are
fully immunized
Private hospital preference
70% - Urban 63% - Rural
 Leakage of funds due to non-
attendance of doctors and health
workers
 No incentives for rural health
entrepreneurship
 Private care is expensive.
 High out-of-pocket expenditure despite
government spending
Causes for low child health indicators:
 Poor quality of government services
 Long waiting periods due to
overburdening
 Lack of government hospitals and
clinics in many areas
Source: National Family Health Survey - 3

3. Government
Targeted public
Private
clinics/hospitals
(voluntary opt in)
Vouchers in child healthcare
 We propose the introduction of healthcare vouchers
for BPL children as a corollary to public health services.
Vouchers
Vouchers
Vouchers
Services
Voucher eligibility:
Children below 6 years of age
Vouchers redeemable for:
1. Immunisation
2. Diagnosis
3. Treatment
4. Medicine
Voucher scheme to be
integrated with:
1. Integrated Child
Development Scheme
2. ASHA (Community health
workers) scheme
3. Sambhav Maternity
Voucher Scheme

4. Why voucher systems will work
Vouchers increase competitionVouchers improve choice
Vouchers improve targeting
Poverty line
o Vouchers are direct and reduce
leakages
o Vouchers increase usage of
under-utilised services
o Vouchers open up new markets
for the private sector and
encourage entrepreneurship in
given areas

5. Why vouchers will work best
Public hospitals
• Unpopular (-)
• Poor service (-)
• Overburdened(-)
• Extensive reach
(+)
• Incentives for
corruption (-)
• Bad targeting (-)
Cash transfers
• Choice (+)
• Incentive for
health
entrepreneurship
(+)
• Competition =
better services
(+)
• Targeted (+)
• Misuse (-)
Vouchers
• Choice (+)
• Incentive for
health
entrepreneurship
(+)
• Competition (+)
• No misuse (+)
• Targeted (+)
• Quality control (+)
• High transaction
costs (-)
Supply side
intervention
Demand side
intervention
Demand side
intervention

6. Implementation of the scheme
Ministry of Health
and Family
Welfare
Households with
children and/or
pregnant women
Accredited Social
Health Activist
(ASHA)/Community
Health Worker
Private
hospitals,
clinics and
mobile
hospitals
Accreditation
Accreditation
Monitoring
Vouchers
Vouchers
Vouchers
1. Once the voucher scheme is
rolled out, only villages
with no access to private
health services must be
prioritised for the
construction of new
Anganwadi Centres (AWCs)
under the ICDS.
2. The Sambhav voucher
scheme for maternal health
to be expanded along with
the child health voucher
scheme.
3. ASHAs already get
incentives to provide
vouchers to BPL families and
ensure they use them.
Opt-in
Services

7. Cost estimation
Cost of covering every BPL child under 6 years of age in urban Delhi1:
1. This is nearly the same model of cost estimation used in the RTE. The figure does not
include transaction, and administrative costs as these are difficult to estimate without a pilot
scheme. The only reliable figures currently available for immunisation are from Banerjee et
al (2010).
2. WHO estimates for average outpatient cost for a private hospital in urban India. Private
services are usually willing to negotiate a lesser price in a voucher scheme.
3. Number of days/year of healthcare.
Rs.
109[2] 10[3] 2.9
lakh
Rs. 32.4
crore
Cost Days/year BPL children

8. Funding and scalability
To ensure
continuity and
sustainability.
Rs. 30,477 crore:
Amount earmarked
for health in the
12th plan.
Diversion of some
funds allotted for
ICDS.
Public
funding
Urban BPL
children
Rural BPL
children
All rural and
urban BPL
families
I. Scaling up improves efficiency due to fewer administrative costs and more
specialization.
II. Use of existing and new private infrastructure makes scaling up relatively easy.
III. The goal is to provide universal access to quality healthcare.

9. Monitoring mechanisms
• Health indicators like infant mortality rate, diseases and malnutrition.
• People’s satisfaction with the scheme and private providers.
• People’s awareness about health and immunization issues.
National Family Health Survey
• Monthly audit of a random sample of hospitals to monitor quality, misuse,
satisfaction and awareness. Also monitor working of ASHAs.
First 3 months
• Annual audits to monitor quality and prevent misuse.
• Inspectors posing as voucher patients to assess treatment and quality of care.
After 3 months
• For anonymous complaints and grievance redressal.
• Helpline number to be printed on vouchers.
Phone helpline
• To be drawn up in consultation with the hospitals. Specifying quality standards.
Contracts with hospitals
• Immediate de-accreditation of hospitals that misuse the scheme. De-accredited
hospitals cannot receive reimbursement for vouchers.
Defaulting hospitals

10. Impact assessment
Impact can be assessed based on the following parameters:
Health indicators
• Infant mortality rate
• Current monthly status
of:
• Acute respiratory
infection
• Fever
• Diarrhoea
• Vaccination status
Attitude and knowledge*
• Attitude to:
• Formal healthcare
• Institutional
deliveries
• Vaccination
• Knowledge of good
healthcare practices
• Reported satisfaction
with the scheme
Supplier indicators
• New hospitals in
voucher areas
• Number of accredited
and de-accredited
hospitals
• Change in quality of
service
• Vouchers distributed
and vouchers
redeemed
*Since vouchers are known to increase utilization of under-utilized services and create
knowledge of and enthusiasm for these services.

11. Challenges and mitigation factors
• Monitoring, phone helpline and immediate de-accreditation.
• Automatic checks through competition from other hospitals
Hospitals over-diagnose to earn vouchers
• Unique codes on vouchers which are then tallied electronically, even by
SMS.
• Community health workers to keep records of distribution of vouchers.
Counterfeiting of vouchers
• Regular revision of voucher value to accommodate rising costs and inflation.
• Consulting private hospitals while fixing voucher rates.
Hospitals lose interest in the scheme
• Encouraging health entrepreneurship through easy licensing and land
acquisition policies.
• Create competition by awarding contracts through public tenders.
There are not many private services to choose from
• Maintaining a fund for emergency expensive treatment which the hospital
can access if the vouchers do not cover the costs.
Patients requiring expensive treatment are turned away

12. References
i. Banerjee, Abhijit Vinayak, Esther Duflo, Rachel Glennerster, and Dhruva Kothari. 2010.
"Improving immunisation coverage in rural India: clustered randomised controlled
evaluation of immunisation campaigns with and without incentives.“ BMJ: British Medical
Journal 340.
ii. Chandramauli, C. 2011. Census of India 2011: provisional population totals paper 1 of
2011 India Series 1, Chapter 6. New Delhi, India: Office of the Registrar General & Census
Commissioner.
iii. Chowdhry, Sonali. 2013. Vouchers for maternal healthcare in India. CCS Internship Papers.
iv. Edejer, Tessa Tan-Torres, ed. 2003. Making choices in health: WHO guide to cost
effectiveness analysis. World Health Organization.
v. IFPS Technical Assistance Project (ITAP). 2012. Sambhav: Vouchers Make High-Quality
Reproductive Health Services Possible for India’s Poor. Gurgaon, Haryana: Futures Group,
ITAP.
vi. International Institute for Population Sciences (IIPS) and Macro International. 2007.
National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS.
vii. State-Wise Percentage of Population Below Poverty Line by Social Groups, 2004-05.
Ministry of Social Justice and Empowerment.