Open Access Study protocol

Evaluation of the impact of the voucher and accreditation approach on improving reproductive behaviors and status in Cambodia

Benjamin Bellows1, Charlotte Warren1, Saphonn Vonthanak2, Chhea Chhorvann3, Hean Sokhom4, Chean Men4, Ashish Bajracharya5*, Ubaidur Rob6 and Tung Rathavy7

Author Affiliations

1 Population Council, General Accident House, Ralph Bunche Road, PO Box 17643-00500, Nairobi, Kenya

2 National Institute of Public Health, No.2, Kim Yl Sung Blvd, Khan Toul Kork, Phnom Penh, Cambodia

3 Research Unit, National Center for HIV/AIDS, Dermatology and STDs (NCHADS), Phnom Penh, Cambodia

4 Center for Advanced Studies (CAS), #160, Street 156, Sangkat Teuk Laak 2, Tuol Kork, Phnom Penh, Cambodia

5 Population Council, Vietnam, Unit 17-04 Prime Center, 53 Quang Trung Street, Hai Ba, Trung District, Hanoi, Vietnam

6 Population Council, Bangladesh, House 21, Road 118, Gulshan, Dhaka 1212, Bangladesh

7 Ministry of Health, National MCH Center (NMCHC), Rm 318, 2nd Fl. National MCH Institute bldg. #31A Street 47 (Street France) Sangkat Srah Chak, Khan Daun Penh, Phnom Penh, Cambodia

For all author emails, please log on.

BMC Public Health 2011, 11:667  doi:10.1186/1471-2458-11-667

Published: 24 August 2011



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.


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.


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.

Vouchers; Output based approach