Community-level effect of the reproductive health vouchers program on out-of-pocket spending on family planning and safe motherhood services in Kenya

  • BMC Health Services Research, Volume 15, No. 1, Year 2015

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Study Justification:
– The study examines the community-level effect of the reproductive health vouchers program on out-of-pocket expenditure on family planning, antenatal, delivery, and postnatal care services in Kenya.
– The effectiveness of vouchers in protecting individuals from financial catastrophe and impoverishment depends on factors such as service availability, transport costs, and community perceptions about the quality of care.
– The study aims to determine whether the vouchers program successfully reduces out-of-pocket spending on safe motherhood services at health facilities.
Highlights:
– The study used two rounds of cross-sectional household surveys in voucher and non-voucher sites.
– Significant declines were observed in the proportions of women from voucher sites who paid for antenatal, delivery, and postnatal care services at health facilities compared to those from non-voucher sites.
– The changes were consistent with increased uptake of the safe motherhood voucher in intervention sites over time.
– There was no significant difference in changes in the proportions of women from voucher and non-voucher sites that paid for family planning services.
– Differences were found in changes in the amount paid for family planning and antenatal care services by women from voucher compared to those from non-voucher sites.
– The reproductive health vouchers program in Kenya significantly contributed to reductions in the proportions of women in the community that paid out-of-pocket for safe motherhood services at health facilities.
Recommendations:
– Expand the reproductive health vouchers program to more areas in Kenya to further reduce out-of-pocket spending on safe motherhood services.
– Conduct further research to understand the factors influencing the effectiveness of vouchers in reducing out-of-pocket expenditure.
– Strengthen service availability and quality in voucher sites to ensure that women have access to the care they need without financial burden.
Key Role Players:
– Government agencies responsible for implementing and expanding the reproductive health vouchers program.
– Funding agencies providing financial support for the program.
– Health facilities participating in the program as voucher service providers.
– Ministry of Health for collaboration and coordination.
– Researchers and data analysts for monitoring and evaluating the program.
Cost Items for Planning Recommendations:
– Funding for program expansion, including the printing and distribution of vouchers.
– Training and capacity building for health facility staff to ensure quality service provision.
– Monitoring and evaluation activities to assess the impact of the program.
– Research and data analysis to understand the factors influencing program effectiveness.
– Communication and awareness campaigns to promote the benefits of the vouchers program.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study used a quasi-experimental design with two rounds of cross-sectional household surveys in voucher and non-voucher sites. The analysis included a comparison of changes in proportions, means, and medians, as well as multivariate linear regression models with interaction terms. However, there are some limitations to consider. The study did not have random assignment of sites to voucher or comparison groups, and the selection of sites was based on specific criteria. Additionally, the study relied on self-reported data, which may be subject to recall bias. To improve the strength of the evidence, future research could consider implementing a randomized controlled trial design and using objective measures of outcomes, such as medical records or administrative data.

Background: Although vouchers can protect individuals in low-income countries from financial catastrophe and impoverishment arising from out-of-pocket expenditures on healthcare, their effectiveness in achieving this goal depends on whether both service and transport costs are subsidized as well as other factors such as service availability in a given locality and community perceptions about the quality of care. This paper examines the community-level effect of the reproductive health vouchers program on out-of-pocket expenditure on family planning, antenatal, delivery and postnatal care services in Kenya. Methods: Data are from two rounds of cross-sectional household surveys in voucher and non-voucher sites. The first survey was conducted between May 2010 and July 2011 among 2,933 women aged 15-49 years while the second survey took place between July and October 2012 among 3,094 women of similar age groups. The effect of the program on out-of-pocket expenditure is determined by difference-in-differences estimation. Analysis entails comparison of changes in proportions, means and medians as well as estimation of multivariate linear regression models with interaction terms between indicators for study site (voucher or non-voucher) and period of study (2010-2011 or 2012). Results: There were significantly greater declines in the proportions of women from voucher sites that paid for antenatal, delivery and postnatal care services at health facilities compared to those from non-voucher sites. The changes were also consistent with increased uptake of the safe motherhood voucher in intervention sites over time. There was, however, no significant difference in changes in the proportions of women from voucher and non-voucher sites that paid for family planning services. The results further show that there were significant differences in changes in the amount paid for family planning and antenatal care services by women from voucher compared to those from non-voucher sites. Although there were greater declines in the average amount paid for delivery and postnatal care services by women from voucher compared to those from non-voucher sites, the difference-in-differences estimates were not statistically significant. Conclusions: The reproductive health vouchers program in Kenya significantly contributed to reductions in the proportions of women in the community that paid out-of-pocket for safe motherhood services at health facilities.

The study used a quasi-experimental design involving two rounds of cross-sectional household surveys in voucher and non-voucher sites. The design was chosen because there was no random assignment of sites to voucher or comparison group. Rather, voucher sites were identified by the Government in collaboration with the major funding agency based on the prevailing reproductive health indicators and availability of health facilities at the time of program inception. Health facilities in the selected sites were then approached to participate in the program and those that satisfied the accreditation criteria were contracted as voucher service providers. The comparison sites were, on the other hand, identified by the researchers in collaboration with the Ministry of Health based on geographical location (being adjacent to the intervention site), population characteristics, and availability of health facilities similar to those in voucher sites in terms of level (hospital, nursing home, health center, and dispensary) and type of ownership (public, private-for-profit and private-not-for-profit). For instance, if the intervention site had a public referral hospital, the comparison site chosen was the neighboring county that also had such a health facility. The approach was informed by the belief that neighboring counties would have populations with similar characteristics. In addition, populations living near a health facility of a certain level and type should ideally have access to the same type of health care services. The first survey was conducted between May 2010 and July 2011 among 2,933 women aged 15–49 years while the second survey took place between July and October 2012 among 3,094 women of similar age groups. Respondents were identified from sub-locations (the smallest administrative units in Kenya) within five-kilometre radius to the health facilities that were accredited to offer services to voucher clients in four of the five program Counties (Kiambu, Kilifi, Kisumu and Kitui) and similar non-contracted facilities (in terms of level and type of ownership) in three comparison sites (Makueni, Nyandarua and Uasin Gishu Counties). A two-stage sampling process was used. The first stage was a random sample of 14 sub-locations in each County from within five kilometres of the selected health facilities in voucher and comparison sites. Geographical positioning system (GPS) coordinates of the facilities were used to identify sub-locations that provided the sampling frame. The second stage entailed a random sample of three villages from each of the selected sub-locations. In each of the sampled villages, the local administration assisted with identifying the poorest households for inclusion in the study. Interviewers then administered the poverty grading tool that is used by the voucher management agency to target beneficiaries to the identified households to further confirm eligibility. The rationale for using the approach was used to capture as many individuals who would qualify for the vouchers as possible given that vouchers are not randomly assigned to beneficiaries. A total of 400 women (75 % poor and 25 % non-poor women for comparison) were targeted in each County in order to detect significant differences in key reproductive health indicators between voucher and comparison sites at 95 % confidence level with 80 % power [25]. More poor than non-poor women were targeted in each County in order to increase the chances of interviewing those who had actually used the voucher as opposed to simply qualifying based on the poverty grading scores. In each selected household, women aged 15–49 years who gave birth in the past 12 months before the survey or were pregnant at the time of the interview were targeted for individual interview. In case the selected household did not have such a member, any female member of reproductive age (15–49 years) who was willing to be interviewed was approached to participate in the study. For households with two or more eligible female members, the youngest was interviewed because they are likely to be more disadvantaged in terms of accessing reproductive health services compared to older women. Respondents provided information on household assets and amenities, health-related household arrangements, food security, household expenditures on goods and services, individual background characteristics (age, education level, religious affiliation, and marital and employment status), general health status and health care utilization, childbearing experiences and intentions, as well as awareness, use and perceptions about vouchers. Women who had given birth in the five years before the survey further provided detailed information on each of the births including whether and where antenatal, delivery, and postnatal care services were sought. In the first survey, women were further asked whether they paid for safe motherhood services for the most recent birth and how much they paid. In the second survey, the questions on payments were asked for each of the births occurring in the five years preceding the survey. Analysis of payments for safe motherhood services focuses on the most recent live birth occurring within two years before the interview in order to avoid overlap of births across surveys. A total of 951 women reported having a birth in the two years preceding the first survey (590 in voucher and 391 in non-voucher sites) while in the subsequent survey, 1,549 women reported having a birth during the reference period (915 in voucher and 634 in non-voucher sites). In both surveys, all women were asked about their knowledge and use of family planning, whether they paid for family planning services the last time they obtained a method, and how much they paid. Analysis of payments for family planning services focuses on women who used a method in the 12 months preceding the survey. The interviews were conducted in Kiswahili, English or the local language after obtaining written informed consent from respondents. The survey tool was pre-tested among a group of women with characteristics similar to those who were targeted for inclusion in the study in order to identify questions that required modification. The study obtained ethical clearance from the Institutional Review Board of the Population Council (Protocol No. 470) and the Ethics Review Committee of the Kenya Medical Research Institute (Protocol No. 174). Analysis is in two parts and entails difference-in-differences estimation, that is, the difference in changes over time between women from voucher and non-voucher sites [26]. The first part is a comparison of changes in proportions of women who obtained family planning, antenatal, delivery and postnatal care services from health facilities and paid for the care they received as well as the average and median amounts paid over time (in Kenya Shillings) in voucher and non-voucher sites. The second part of the analysis involves estimation of multivariate linear regression models to examine the differences in changes in the proportions paying and the amount paid for family planning and safe motherhood services at health facilities over time between voucher and non-voucher sites. The basic model includes an interaction term between survey year and study site and adjusts for clustering of individuals at the sub-location level. The basic form of the model is specified as follows: The parameter X1 in Equation (1) is the indicator for study round, X2 is the indicator for study site, Xij is the vector of other covariates included in the model for individual i from sub-location j, and β is the associated vector of fixed parameters. The parameter α0 represents the outcome for women from non-voucher sites at baseline (in 2010-2011); α1 is the change in the outcome between baseline and follow-up among women from non-voucher sites; α2 is the difference in the outcome between women from voucher and non-voucher sites at baseline; α3 represents the difference in the changes in the outcome between women from voucher and non-voucher sites over time (difference-in-differences estimate); and εj are the unobserved characteristics of women from the same sub-location that might be correlated with the outcome of interest. Two sets of models were estimated for each of the reproductive health indicators considered, namely, family planning, antenatal, delivery and postnatal care. The first set of models had a binary outcome of whether the respondents paid for services or not while the outcome for the second set of models was the amount paid for services. The models controlled for education level, marital status, type of place of residence, duration of residence, poverty status, parity, and type of facility where services were sought. In addition, the models for safe motherhood services controlled for maternal age at the time of the most recent birth while the models for family planning services controlled for age of the respondent at the time of interview. Table 2 presents the definitions and measurement of the variables included in both models. Definition and measurement of variables used in multivariate analysis aBased on the poverty grading tool used by the voucher management agency to identify beneficiaries; KSh: Kenya Shilling

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The study examined the community-level effect of a reproductive health vouchers program on out-of-pocket expenditure for family planning, antenatal, delivery, and postnatal care services in Kenya. The program aimed to reduce financial barriers to accessing safe motherhood services by subsidizing service and transport costs. The study used a quasi-experimental design involving two rounds of cross-sectional household surveys in voucher and non-voucher sites. The results showed that there were significantly greater declines in the proportions of women from voucher sites who paid for antenatal, delivery, and postnatal care services compared to those from non-voucher sites. However, there was no significant difference in changes in the proportions of women from voucher and non-voucher sites who paid for family planning services. The study also found significant differences in changes in the amount paid for family planning and antenatal care services by women from voucher compared to those from non-voucher sites. Although there were greater declines in the average amount paid for delivery and postnatal care services by women from voucher sites, the difference-in-differences estimates were not statistically significant. Overall, the reproductive health vouchers program in Kenya significantly contributed to reductions in the proportions of women in the community who paid out-of-pocket for safe motherhood services at health facilities.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health based on the study is the implementation of a reproductive health vouchers program. This program would provide subsidies for family planning, antenatal, delivery, and postnatal care services, reducing the out-of-pocket expenditure for women in low-income communities in Kenya. The program would target areas with limited service availability and work to address community perceptions about the quality of care. By implementing this program, there were significant reductions in the proportions of women from voucher sites who had to pay for safe motherhood services at health facilities. However, there was no significant difference in changes in the proportions of women from voucher and non-voucher sites who paid for family planning services. The program also showed significant differences in changes in the amount paid for family planning and antenatal care services by women from voucher sites compared to those from non-voucher sites. Although there were greater declines in the average amount paid for delivery and postnatal care services by women from voucher sites, the difference-in-differences estimates were not statistically significant. Overall, the reproductive health vouchers program in Kenya significantly contributed to reducing the financial burden on women accessing safe motherhood services at health facilities.
AI Innovations Methodology
The study mentioned in the description focuses on the community-level effect of a reproductive health vouchers program on out-of-pocket expenditure for family planning and safe motherhood services in Kenya. The methodology used in the study involves two rounds of cross-sectional household surveys in voucher and non-voucher sites. Here is a brief description of the methodology:

1. Selection of voucher and non-voucher sites: Voucher sites were identified by the Government and major funding agency based on reproductive health indicators and availability of health facilities. Health facilities in these sites were approached to participate in the program. Non-voucher sites were selected by the researchers in collaboration with the Ministry of Health based on geographical location, population characteristics, and availability of similar health facilities.

2. Data collection: Two rounds of cross-sectional household surveys were conducted. The first survey was conducted between May 2010 and July 2011, and the second survey took place between July and October 2012. Respondents were women aged 15-49 years who had given birth in the past 12 months before the survey or were pregnant at the time of the interview. The surveys collected information on household assets, health-related arrangements, individual background characteristics, health care utilization, and awareness, use, and perceptions about vouchers.

3. Sampling process: A two-stage sampling process was used. In the first stage, random samples of sub-locations within a five-kilometer radius of selected health facilities were chosen. In the second stage, three villages were randomly selected from each sub-location. The poorest households in each village were included in the study. A total of 400 women (75% poor and 25% non-poor women for comparison) were targeted in each county.

4. Analysis: The analysis used a difference-in-differences estimation approach. Changes in proportions, means, and medians were compared between voucher and non-voucher sites. Multivariate linear regression models were used to estimate the differences in changes in proportions paying and the amount paid for family planning and safe motherhood services between voucher and non-voucher sites. The models controlled for various factors such as education level, marital status, poverty status, and type of facility where services were sought.

The study found that the reproductive health vouchers program in Kenya significantly contributed to reductions in the proportions of women in the community who paid out-of-pocket for safe motherhood services at health facilities.

In terms of potential recommendations to improve access to maternal health, based on the findings of the study, one recommendation could be to expand the reproductive health vouchers program to more areas in Kenya. This could help reduce out-of-pocket expenditure for safe motherhood services and improve access for women in those areas. Additionally, efforts could be made to increase awareness and knowledge about the program among women and communities to encourage uptake.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could involve conducting similar cross-sectional household surveys in the areas where the program is expanded. The surveys would collect data on out-of-pocket expenditure, service utilization, and perceptions about the quality of care. The difference-in-differences estimation approach could be used to compare changes in access and expenditure between the areas with the expanded program and areas without the program. This would help assess the effectiveness of the recommendations in improving access to maternal health.


Statistics:
Citations: 9
Identifiers:
DOI: 10.1186/s12913-015-1000-3
Research Areas:
Community Interventions, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Kenya
Study Design:
Cohort Study, Cross Sectional Study, Quasi Experimental Study, randomised-control-trial
Study Approach:
Quantitative
Participants Gender:
Female
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