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Background: Innovative financing strategies such as those that integrate supply and demand elements like the output-based approach (OBA) have been implemented to reduce financial barriers to maternal health services. The Kenyan government with support from the German Development Bank (KfW) implemented an OBA voucher program to subsidize priority reproductive health services. Little evidence exists on the experience of implementing such programs in different settings. We describe the implementation process of the Kenyan OBA program and draw implications for scale up. Methods. Policy analysis using document review and qualitative data from 10 in-depth interviews with facility in-charges and 18 with service providers from the contracted facilities, local administration, health and field managers in Kitui, Kiambu and Kisumu districts as well as Korogocho and Viwandani slums in Nairobi. Results: The OBA implementation process was designed in phases providing an opportunity for learning and adapting the lessons to local settings; the design consisted of five components: a defined benefit package, contracting and quality assurance; marketing and distribution of vouchers and claims processing and reimbursement. Key implementation challenges included limited feedback to providers on the outcomes of quality assurance and accreditation and budgetary constraints that limited effective marketing leading to inadequate information to clients on the benefit package. Claims processing and reimbursement was sophisticated but required adherence to time consuming procedures and in some cases private providers complained of low reimbursement rates for services provided. Conclusions: OBA voucher schemes can be implemented successfully in similar settings. For effective scale up, strong partnership will be required between the public and private entities. The governments role is key and should include provision of adequate funding, stewardship and looking for opportunities to utilize existing platforms to scale up such strategies. © 2012 Abuya et al.; licensee BioMed Central Ltd.
There is an increasing recognition of the role of policy analysis in public health evaluation [9]. In addition, health system interventions have unpredictable paths of implementation and that interpretative, time-dependent decisions by different actors underpin the subsequent implementation process. We utilize the policy analysis framework, which emphasizes the need to take account of who (actors) and how (process) decisions are made, what (content) decisions are made and under what conditions (context) [10]. In addition, we examine the role of actors and their influence as a central theme through a stakeholder analysis [11,12] to draw out programmatic lessons for scale up. This paper draws from two sets of data. First, a document review was conducted of available project and evaluation reports, publications and other relevant documents on the voucher project. From this we generated evidence on the dynamics of implementation, activities conducted and the decisions made over time. Documentary materials included seven design reports and contractual documents, five annual and midterm review reports, eight advisory and 20 steering committee minutes including four back-stopping mission reports. The second set of data was qualitative interviews collected as part of the evaluation activities of the OBA programme in Kenya [13]. The overall aim of the qualitative component was to gain a deeper understanding of the perceptions of the actors on the programme. This paper draws from in-depth interviews (IDIs) conducted across five program sites: Kitui, Kiambu and Kisumu districts as well as Korogocho and Viwandani slums in Nairobi. Ten IDIs were conducted with health facility in-charges and 18 with service providers from the contracted facilities, District Medical Officers, Public Health Officers, local leaders and field managers. In each site, a team of trained researchers conducted interviews with a standardized guide. Discussions with contracted providers, facility in-charges and field managers focused on their perceptions of programme design including accreditation, reimbursements, referral mechanisms, voucher distribution and perceived barriers to programme implementation. Interviews with local leaders examined access to reproductive health services and general community perceptions about the services, awareness of the programme, perceived impact and barriers to use of the vouchers at the community level. Where consent was given qualitative interviews were recorded translated into English, transcribed and typed into Microsoft Word software. Debriefing sessions were held by the research team after each interview to provide an overview of issues raised. Informal analysis was conducted and summaries of the collected data made after each session for clarification or follow up. The data were stored and managed using QSR Nvivo8 Software (© QSR international Pty 2007, Australia). Analysis of qualitative data entailed categorisation of issues based on inductive and deductive approaches by which a priori themes were used as a starting point. Later the thematic framework was improved as more data were examined [14]. Regular consultations were held with other members of the research team to enhance reflexivity. The analysis was also enriched by useful insights from members of the research team especially CW who was involved in the inception phase of the pilot program. Their views were useful in the interpretation on the role of actors and their influence on the implementation experiences. Themes generated were further compared against analysis charts, which were developed based on the policy analysis framework [10]. Analysis charts were compared within and across sites to look for similarities and differences of key issues around implementation processes. Final analysis was organised around a description of the implementation process, role of actors, and power dynamics. A range of analyses examined experience within and across sites, with a view to identify complex interactions between key explanatory factors that account for the implementation practices at both national and district levels. We further drew from a complementary body of work on how to investigate power [15] to generate evidence on the importance of power dynamics on implementation of programs. Ethical approvals were granted from Population Council Institutional Review Board and the Kenya Medical Research Institute (KEMRI) Ethics and Research Committee. Written informed consent were obtained from all the interviewees. To protect the identity of participants at the point of data collection and reporting is an important ethical procedure. However, a dilemma recognised in this study is lack of complete anonymity of data especially during reporting given the small number of actors being interviewed. Attempts were made to minimise these problems and strike a balance between the value of providing information on implementation experiences and anonymising participants. Interviewees were also given the options of not using voice recorders during interviews and to omit their quotes in reports and papers. Another measure used to maintain anonymity in reporting was the use of broad actor groups to indicate the perspective of the information without linking to a particular actor. This was important as certain information was considered sensitive but necessary to illustrate challenges of implementation.
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