Table 1.

Operational challenges of introducing voucher program in the public sector and ways of addressing them

Operational challenges	Mechanisms to address the challenges
There exists a lot of bureaucracy at the senior government levels which can delay the process of engaging the public facilities in the voucher program and later managing the relationship between VMA and public facilities.	▪ “There should be dialogue from the national level between the MoH and VMA to come to a consensus on how to introduce the program to the public sector without contradicting government policy.”
Public facilities are traditionally run by government funds at the district level. Will voucher funds go to district office or will they go directly to the facilities?	▪ “Funding should come in directly to the facilities to cut down the burden of bureaucracy and prevent [potential] fraud.”
	▪ “A memorandum of understanding can be signed between the VMA and each hospital management to address the concerns.”
How will the voucher program operate in line with government policy of providing free health for all?	▪ “Voucher program can be introduced on the back of government sanctioned private wards where clients are already paying for services.”
	▪ “Politicians, religious leaders and other community gate keepers should be involved so that the program can gain acceptability within the communities.”
Would under-staffing of public hospitals and lack of RH supplies negatively affect quality of OBA services? How will public facilities benefit from funds accrued from the voucher program?	▪ “Extra funding from the voucher program can be used to hire staff, improve pay, purchase supplies and improve general quality of services. With an improved work environment, staff morale is also likely to go up. Enhancing capacity building will also help to improve staff morale.”
What is the sustainability of the RH voucher program after the end of OBA program/funding?	▪ “Private wards operate in many public referral hospitals and the voucher program could be contracted to operate there. With funding from the voucher program, the private wing will be able to build facility capacity. Depending on the duration of the program, the infrastructure investment could be used beyond the life of the program. Better services in these private wings will encourage utilization for non-voucher, paying clients and will help to sustain the facility.”

MoH: Ministry of Health; VMA: Voucher Management Agency; Output-based Approach.