Sustain Bridging the Gap International policy case studies

Advocating for voucher schemes and fruit and veg on prescription

Executive summary

This Bridging the Gap scoping report explores fruit and veg vouchers and prescriptions as avenues for improving health outcomes and promoting community well-being. These interventions allow people on lower incomes to access fresh produce through local supply chains while building community wealth.

How do you differentiate between voucher schemes and prescriptions?

This report explores two pathways: voucher schemes partnered with markets and the use of fruit and vegetable prescriptions in partnership with healthcare practitioners. The latter provide fruits and vegetables for free or at a lower cost, with health insurers often covering some or all the expenses. These programmes represent a “food as medicine” intervention and has attracted interest from clinicians, clients, and policymakers.

What were the findings?

The integration of healthcare services with nutritional incentives emerges as a promising avenue for empowering individuals to make informed and healthy food choices. Advocacy is essential to the widespread adoption of both voucher schemes and prescription programmes, along with translation support, streamlined application processes, strong partnerships with local markets and government funding.

Common challenges include low awareness, rigid eligibility criteria, limited retailer participation, seasonal limitations and the erosion of the voucher value over time. The level of coordination needed can also pose a challenge, highlighting the need for collaboration and government support to minimise funding, outreach and retailer participation issues. None of the initiatives discussed mention organic or agroecologically grown produce specifically — a noteworthy gap.

About this report

This report explores both regional and national voucher schemes and prescription models which promote a healthy diet and widen access to fresh, nutritious produce. For each intervention, the report highlights benefits, challenges, enablers and outcomes, as well as key takeaways and opportunities.

The interventions included are:

  1. Healthy Start (England): Expand eligibility for the Healthy Start scheme.
  2. Best Start (Scotland): Prepaid cards.
  3. Farmers Market Nutrition Coupon Program (Canada): Expansion into farmers markets.
  4. Schemes expanding SNAP programs:
  1. Produce Prescriptions: Advocate for the rollout of produce prescription programs.

 

This simple traffic light system is used throughout to illustrate how well each policy/intervention adheres to Bridging the Gap’s main aims: increasing organic supply and increasing access.

Organic Access

No mention of organic

Some mention of organic

Strong mention of organic

No mention of increasing access 

Some mention of increasing access 

Strong mention of increasing access 

 

Deep dive: Interventions & policies

 

Healthy Start

No mention of organic

Strong mention of increasing access

KEY FACTS

  • Location: UK
  • Initiated: 2006 (ongoing)
  • Type: Voucher
  • Owner: NHS
  • Aim: Promote a healthier diet during pregnancy and early childhood.
  • Mechanism: Provides vouchers to pregnant women and families with young children, helping them purchase £4.25 worth of fruit, vegetables and milk per week.

BENEFITS

CHALLENGES

Nutritional support: the Healthy Start scheme supports access to essential nutritional items.

Reduced financial pressure: it has helped reduce financial pressure on households by providing financial support for the purchase of nutritious foods.

Low awareness: there is a significant lack of awareness about the Healthy Start scheme among the general population, as well as certain subgroups including non-English speakers, individuals with low literacy levels, working families on low incomes and families with changing incomes.

Eligibility criteria: the income threshold (earning less than £408 a month) can be rigid and problematic for families with fluctuating incomes or those in low-paid work. Changes in income can lead to families being in and out of their entitlement, making it difficult to access the benefits consistently.

Application process: the application process may pose a barrier for some eligible families.

Limited retailer participation: access to registered retailers accepting Healthy Start vouchers can be a challenge, especially in rural areas. Smaller shops and market stalls serving culturally diverse communities may have low registration.

Erosion of voucher value: the value of the vouchers may erode over time relative to the rising cost of healthy food, reducing effectiveness.

ENABLERS

OUTCOMES

Funding: the scheme is supported and funded by government.

 

Improved eating habits: the scheme has influenced people's shopping and eating habits by encouraging young families to experiment with different fruit and vegetables, leading to better quality and a wider variety of food choices.

OPPORTUNITIES FOR BTG

Bridging the Gap could advocate for expanding eligibility of the Healthy Start scheme.

 

Best Start

No mention of organic

Strong mention of increasing access

KEY FACTS

  • Location: Scotland
  • Initiated: 2018
  • Type: Voucher
  • Owner: Social Security Scotland
  • Aim: Promote a healthier diet during pregnancy and early childhood.
  • Mechanism: A prepaid card, with a value of £19.80 per month, that can be used in shops or online to buy healthy produce.

BENEFITS

CHALLENGES

Payment card: recipients prefer Best Start Foods over the previous Healthy Start Vouchers system due to the discreet and convenient nature of the payment card.

Healthier shopping habits: supported healthier shopping habits and meal planning, resulting in mothers and children consuming healthier foods.

Reduced financial pressure: helped reduce financial pressure on households by providing financial support for the purchase of nutritious foods.

Variety of retailers: the card's flexibility allowed recipients to shop at different retailers to find the best prices and a wider range of food options.

Application processing times: application processing times have generally increased over time. In 2021-22, 51% of approved applications took more than 20 working days to process, indicating potential delays in benefit disbursement.

Lack of comprehensive retailer information: recipients called for more detailed guidance on the list of retailers where the Best Start Foods card can and cannot be used, as well as guidance for using the card for online shopping and delivery.

Shopping habits: some recipients found it challenging to adjust their shopping habits as their child(ren) aged and their payment amount changed.

ENABLERS

OUTCOMES

Promotion and outreach: high take-up rates rely on effective promotional efforts and outreach programs.

Clear application process: to ensure that individuals can easily apply for and access the Best Start benefit, a clear application process is essential.

Retailer participation: effectiveness is closely tied to the willingness and availability of a wide range of retailers to accept the Best Start Foods card.

Multilingual support: providing multilingual support and materials made it easier for non-English speakers to understand and use the payment card, thus increasing accessibility.

Improved take-up rates: 88% of eligible individuals claimed the benefit in 2021/22, demonstrating its success in reaching eligible recipients.

OPPORTUNITIES FOR BTG

Prepaid cards are preferable to paper vouchers. BTG could recommend scaling the use of these cards as the child grows and/or in line with inflation.

 

Farmers Market Nutrition Coupon Program

No mention of organic

Strong mention of increasing access

KEY FACTS

  • Location: British Columbia, Canada
  • Initiated: 2007
  • Type: Voucher
  • Owner: British Columbia Association of Farmers Market
  • Funder: Ministry of Health and partners of BCAFM
  • Aim: Bolster food security and sustain farmers’ market.
  • Mechanism: Distribute coupons to lower-income families, pregnant individuals and seniors. These are redeemable at all BCAFM member farmers’ markets.

BENEFITS

CHALLENGES

Improved food security: bolsters food security by providing access to fresh and nutritious food, including vegetables, fruits, nuts, eggs, dairy, and more.

Support for farmers’ markets: the programme sustains farmers’ markets in British Columbia by encouraging consumers to shop at these local markets, thereby supporting local growers and the community.

Financial assistance: participants can receive up to $27 per week in coupons, helping them afford a wider variety of healthy foods.

Health promotion: promotes healthy eating habits by encouraging participants to purchase fresh and locally grown produce.

Limited funding: limited funding and capacity constraints lead to high demand and variations in programme availability across different communities.

Seasonal limitations: not all BC Farmers' Markets operate throughout the entire year, which can limit the duration of coupon usage.

Access to coupons: participants must go through local community partner organisations to access the coupons, and capacity may vary among partners.

ENABLERS

OUTCOMES

Government funding: The programme is supported by the Province of British Columbia and the Ministry of Health, which provides essential funding for its operation and expansion.

Community partners: community partner organisations play a crucial role in distributing coupons and facilitating the programme at the local level.

Programme expansion: the programme began as a pilot project in 2007 and, as of 2023, operates in approximately 85 communities across BC.

Increased funding: secured three-year funding of over $12 million, which includes an increase in the coupon value from $21 to $27 per week.

Positive redemption rate: achieved an 88% redemption rate, indicating the effectiveness of the initiative in encouraging participants to use the coupons at farmers' markets.

Improved nutrition: 98% of participants reported eating more fruits and vegetables.

Support for local farmers: directed over $3.2 million in coupons and fresh food directly to BC farmers, supporting local agriculture.

OPPORTUNITIES FOR BTG

This example showcases the importance of fostering community-driver partnerships.

 

GusNip (Gus Schumacher Nutrition Incentive Program)

No mention of organic

Strong mention of increasing access

KEY FACTS

  • Location: USA
  • Initiated: 2014
  • Type: Voucher
  • Funder: U.S. Department of Agriculture’s (USDA) National Institute of Food and Agriculture (NIFA) and Food and Nutrition Service (FNS)
  • Aim: GusNip provides grants on a competitive basis to projects that help low-income consumers access and purchase fresh fruits and vegetables through “cash” incentives that increase their purchasing power at locations like farmers markets.
  • Mechanism: The expanded version of the program offers three distinct funding opportunities for eligible entities: Supplemental Nutrition Assistance Program (SNAP) incentives, produce prescription programmes and training, technical assistance evaluation and information centres.

BENEFITS

CHALLENGES

Health outcomes: the programme’s ability to demonstrate positive impacts on participants' health and eating habits serves as an enabler for continued funding and expansion.

Balancing needs: striking the right balance between supporting local, small-scale farmers and addressing the food access needs of low-income individuals.

Awareness and outreach: raising awareness about the incentives among eligible participants can be challenging.

Funding: ensuring sustainable funding and resources to maintain and expand these programmes, which often rely on grants and financial support to operate effectively.

Limited reach: some programmes may not reach the highest-risk populations, and demographic data suggest that participants may not fully represent the broader population of SNAP users.

ENABLERS

OUTCOMES

Financial support: many of these programmes depend on funding from various sources, including government grants, private donors, and partnerships with local organisations.

Collaboration: partnering with a variety of retailers and outlets expands reach and provides more options for participants.

Government initiatives: programmes like the Food Insecurity Nutrition Incentive (FINI) Program from the USDA provide crucial financial backing and regulatory support.

Benefits to farmers: an evaluation of SNAP incentive programmes in the United States revealed that most farmers and market managers found NIPs at farmers' markets to be very beneficial.

Health improvements: NIP initiatives have shown significant positive impacts on participants' health, contributing to a reduction in diet-related diseases.

SNAP Market Match / SNAP Produce Match (Washington, USA):

This voucher operates at over 120 participating farmers' markets and farm stands across the state. Shoppers can go to a participating store, swipe their SNAP/EBT card for the amount they want to spend and receive that amount in EBT tokens and the same amount in SNAP Market Match dollars. They can then use this to shop for fresh produce. It offers additional benefits for the purchase of fruits and vegetables at participating grocery stores. Shoppers who use their SNAP/EBT card to buy at least $10 in fresh and frozen fruits and vegetables get a coupon which they can use to buy fruits and vegetables next time they shop.

OPPORTUNITIES FOR BTG

-

 

FreshConnect

No mention of organic

Strong mention of increasing access

KEY FACTS

  • Location: NYC, USA
  • Initiated: 2011
  • Type: Farmer’s Market Incentive Programme
  • Owner: New York State Department of Agriculture and Markets (AGM)
  • Aim: Create new farmers’ markets and support existing markets that provide fresh produce to high-need areas.
  • Mechanism: Uses FreshConnect checks and expands SNAP into markets.

BENEFITS

CHALLENGES

Access: increased access to locally grown fresh produce.

Support for local farmers: by encouraging the use of FreshConnect Checks and SNAP benefits at farmers' markets, the programme supports local farmers and stimulates the local agricultural economy.

Incentives for SNAP consumers: providing incentives in the form of $2 coupons for every $5 in SNAP benefits spent at farmers' markets increases the purchasing power of SNAP consumers by 40%.

Expanded eligibility: in 2014, the programme expanded beyond SNAP recipients to include veterans, service members and their immediate family members.

Coordination challenges: lack of coordination between different benefit programmes due to their associations with various funding mechanisms and agencies.

Administrative burden: farmers must navigate the differing protocols associated with accepting benefits from each programme, which may result in delayed reimbursement or confusion.

Funding: ensuring the availability of (ongoing) funds to issue FreshConnect Checks and incentives can be a challenge.

Participant awareness: difficult to ensure that SNAP recipients, Veterans, and Service members are aware of the program and its benefits.

ENABLERS

OUTCOMES

Government support: received support from the government, as seen in Governor Cuomo's launch of the FreshConnect Program and the recent Fresh2You initiative by Governor Hochul.

Local partnerships: collaborating with local farmers' markets, farm stands, and mobile markets is essential to the success of the programme.

Wide reach: FreshConnect Checks may be accepted at any operating farmers’ market or farms stand in New York State where eligible food items are sold and can be used in conjunction with other benefits.

In July 2021, more than 257,000 checks had been issued to 82 sites across the state to help eligible New Yorkers.

The number of farmers’ markets in the U.S. has increased to 8,669 within the last decade and markets are increasingly available to consumers in both rural and urban settings.

OPPORTUNITIES FOR BTG

This example highlights the opportunity to expand voucher schemes to farmers’ markets. Bridging the Gap could advocate for a similar expansion of the Healthy Start scheme.

 

Maine Harvest Bucks

No mention of organic

Strong mention of increasing access

KEY FACTS

  • Location: Maine, USA
  • Initiated: 2015
  • Type: Farmer’s Market Incentive Programme
  • Owner: Maine Federation of Farmers’ Markets (MFFM), Maine Organic Farmers and Gardeners Association (MOFGA), St. Mary’s Nutrition Center (SMNC), and Cultivating Community
  • Funder: USDA Food Insecurity Nutrition Incentive Program (FINI)
  • Aim: Making it more affordable to access fresh, local produce.
  • Mechanism: The Maine Harvest Bucks (MHB) programme increases the purchasing power of individuals using SNAP/EBT to buy fruits and vegetables at participating outlets, such as farmers' markets, CSA programmes, and farm stands.

BENEFITS

CHALLENGES

Access: increased access to locally grown fresh produce.

Bonus vouchers: at farmers' markets, shoppers using SNAP/EBT receive bonus vouchers, allowing them to buy even more fruits and vegetables.

Discounted purchases: at CSA programmes and farm stands, customers typically receive a 50% discount on their fruit and vegetable purchases.

Retail expansion dilemma: when considering expansion into retail, the program must weigh the needs and benefits of both local, small-scale farmers and low-income individuals.

ENABLERS

OUTCOMES

USDA's Food Insecurity Nutrition Incentive Program (FINI): Maine Harvest Bucks is funded through FINI, which provides financial support for nutrition incentive programme, enabling expansion.

Financial support for local farmers: directly benefits local farmers by injecting over $700,000 in local food purchases in 2021. This financial support boosts the income of Maine farmers, supporting the local economy.

Increased SNAP redemption at farmers' markets: SNAP redemption at farmers' markets expanded from $4.2 million in 2009 to $19.4 million in 2015.

Improved fruit and vegetable consumption: nutrition incentive programmes, including MHB, have consistently led to increased fruit and vegetable consumption among program participants. Around 93% of customers using MHB felt they ate "some more" or "a lot more" fruits and vegetables due to the programme.

OPPORTUNITIES FOR BTG

This example shows the effect of increasing purchasing power of customers (through existing voucher schemes) on fruit and vegetable consumption. BTG could call for a similar expansion of the Healthy Start scheme by introducing programmes that could increase the value of the coupon at the point of purchase.

 

Double Up food Bucks Program

No mention of organic

Strong mention of increasing access

KEY FACTS

Location: Oregon, USA

Initiated: 2022

Type: Voucher

Owner: USDA Farmers Market Fund

Aim: Enabling SNAP participants to increase their purchases of local fruits and vegetables.

Mechanism: Dollar-for-dollar incentive at the point of purchase.

NOTES

The Farmers Market Fund in Portland, Oregon, is expanding its Double Up Food Bucks Program to more outlets, allowing SNAP participants to receive a dollar-for-dollar incentive for purchasing local fruits and vegetables. Participants at 80 farmers markets, 10 farm stands, 45 grocery stores and 40 Community Supported Agriculture (CSA) models across Oregon will receive this incentive, making it more affordable to access healthy produce.

 

Produce Prescriptions

No mention of organic

Strong mention of increasing access

BENEFITS

CHALLENGES

Effective: documented success in improving health outcomes.

Eating habits: in the United States, over 100 000 annual deaths from cardiometabolic disease are estimated to be attributable to insufficient fruit and vegetable intake.

ENABLERS

OUTCOMES

Government support: the 2022 White House Conference on Hunger, Nutrition and Health highlighted produce prescriptions as a priority for policy action within the health care system.

An assessment spanning multiple sites and involving individual participants across 12 states in the U.S revealed noteworthy and statistically significant enhancements in the intake of fruits and vegetables, reductions in household food insecurity, improvements in HbA1c, blood pressure (BP), body mass index (BMI), and self-reported health status among adults.

Positive outcomes were observed in terms of fruit and vegetable intake, household food insecurity, and self-reported health status among children.

OPPORTUNITIES FOR BTG

Bridging the Gap could advocate for rolling out produce prescription programmes.

 

Expansion of Healthy Start – Proposal

KEY FACTS

Location: UK

Initiated: 2021

Type: Voucher expansion

Owner: National Food Strategy

Ask: The National Food Strategy in the UK proposes that the government should expand the Healthy Start voucher programme to include all households earning less than £20,000 and having pregnant women or children under the age of five (pg. 152). It also recommends expanding the eligibility criteria for participation.

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