A Policy Analysis of the implementation of a Reproductive Health Vouchers Program in Kenya

Abstract

BackgroundInnovative 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.MethodsPolicy 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.ResultsThe 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.ConclusionsOBA 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 government’s role is key and should include provision of adequate funding, stewardship and looking for opportunities to utilize existing platforms to scale up such strategies.

Implementation of free maternal and child healthcare policies: assessment of influence of context and institutional capacity of health facilities in South-east Nigeria

“…Use of service charters to curb informal payments to service providers [9], active health facility committees (HFCs) including financial management [10–12], timely payment of providers [13], regular and uninterrupted drug supply [13], availability of clear guidelines on use of user fee replacement grants [14], an effective staff sanction framework, which reduces health worker absenteeism [15], have enabled health facilities to effectively implement free healthcare policies. In contrast, barriers to health facilities implementing free healthcare policies include weak decentralization [10,16–18]; poor supervision and monitoring [19,20]; weak referral systems [17]; absence of written implementation guidelines [14,21]; shortage of staff and inconsistent recording and reporting [10,20]; low social accountability and community involvement [9,22–24]; delayed payment of providers [12,21,25]; lack of adequate drug stock [17,18,24,26–31]; mistrust between providers and patients [19,32–34]; absenteeism [10,15,20]; poorly motivated health workers [18,24]; lack of financial incentives [35]; preference for urban postings [19,36]; funding inadequacy in health facilities [16]; inadequate physical infrastructure [18,24,36]; unavailability of guidelines for use of user fee replacement fund [37] and unclear procedures for targeting beneficiaries [3]. …”

Can vouchers deliver? An evaluation of subsidies for maternal health care in Cambodia

“…Vouchers have been introduced in Bangladesh, [1][2][3] China, India, 4 Indonesia, Kenya, 5,6 Pakistan 7 and Uganda and have been associated with increased utilization of maternal health care. 8,9 However, since other interventions have been implemented at the same time, one cannot be sure that the increase is attributable to vouchers alone.…”

Horizontal Inequities In The Uptake Of Hospital Delivery And The Role Of Social Determinants In China

“…Therefore care specific demand side finance may be more effective than wide social protection programs. For that targeted demand side finance approaches like delivery vouchers [30,31] , delivery fee exemptions [32], and conditional cash transfers [33] are all possible effective policy alternatives, with the last two approaches probably more effective, as proposed by the diagonal health system strengthening approach [34]. Meanwhile, the results also sheds light that it is the ability to pay rather than Total -0.110 37.70 59.86 100.00 -0.055 0.00 0.00 100.00 [39].…”