Voucher Program

Category 3

The donor-sponsored ICAS voucher scheme in Nicaragua is an example of effectively employing output-based aid. The voucher program gives patients a choice of provider, encouraging competition and potentially driving down price. ICAS uses donor funding to purchase a pre-determined suite of health services, which are distributed in the form of vouchers to high-risk populations such as sex workers. Pricing for the set of health services is negotiated between ICAS and individual clinics. Clinic enrollment in the program is thus based on price, location, and quality of services. Providers benefit from training in STI treatment, in addition to reliable income and steady patient flow.
Vouchers entitle patients to a consultation, follow-up visit, counseling and testing for HIV and other STIs, labs, and follow-up care for PLHA, including pregnant women. The program partners with community-based organizations that work with high-risk populations to distribute vouchers. Clinics are compensated by ICAS according to the vouchers and data collection sheets returned. The program reduced the prevalence of gonorrhea, syphilis, and trichomonas in the lowest strata of sex workers from 1996 to 2005. Because STIs increase the transmission of HIV, a decrease in STIs can reduce the transmission of HIV.

Goal of the Practice
  • Utilize demand-side financing approaches, linking public funding to delivery of healthcare.
  • Provide sexually transmitted infections (STI) and HIV/AIDS services, sexual health, and reproductive health services for high risk populations, such as sex-workers and drug-addicts.
Core Components
  • Clinician training for treating STIs and HIV/AIDS for MARPs
  • "Best practice" STI, HIV/AIDS, reproductive health and family planning services free of charge for MARPs and poor adolescents
Noteworthy Results
  • Between 1995 and mid 2008 almost 150,000 vouchers were distributed, 37,216 medical consultations provided: 22,082 to populations at-risk and 15,134 to adolescents. One study showed a considerable reduction of the STIs syphilis and trichomonas in female sex-workers from 1996 to 2005, and HIV prevalence remained <5 percent. Female adolescent voucher receivers have a higher use of services compared with non-receivers. At schools, sexually active receivers had a higher use of contraceptives than non-receivers; in neighborhoods, condom use was greater among voucher receivers than non-receivers.
Lessons Learned
  • The administrative cost of running this program is high, with almost half of the total cost of running the program spent on personnel. Also, funding comes from multiple and varied sources, accentuating the importance of considering sustainability and scalability of funding and program management before implementing a similar project.
  • This model allows for targeted and testable interventions that can be layered with existing health offerings that might otherwise not serve high-risk populations.
Focus Areas
Counseling and Testing
Private Sector
Implemented By
The Central American Health Institute (Instituto CentroAmericano de la Salud) (ICAS)
Participating Organization
  • Global Fund
  • NicaSalud
  • NOVIB (Dutch NGO)
  • Elton John AIDS Foundation
  • Mexican National Public Health Institute
Latin America & Caribbean
Clinic/Health facility
Target Population
  • General Public
  • Sex Workers (SW)
  • Injecting Drug Users (IDU)
10000 - 25000
Implementation Years
01/2010 - ongoing