Can Reproductive Health Voucher Programs Improve Quality of Postnatal Care? A Quasi-Experimental Evaluation of Kenya’s Safe Motherhood Voucher Scheme

Abstract

This study tests the group-level causal relationship between the expansion of Kenya’s Safe Motherhood voucher program and changes in quality of postnatal care (PNC) provided at voucher-contracted facilities. We compare facilities accredited since program inception in 2006 (phase I) and facilities accredited since 2010-2011 (phase II) relative to comparable non-voucher facilities. PNC quality is assessed using observed clinical content processes, as well as client-reported outcome measures. Two-tailed unpaired t-tests are used to identify differences in mean process quality scores and client-reported outcome measures, comparing changes between intervention and comparison groups at the 2010 and 2012 data collection periods. Difference-in-differences analysis is used to estimate the reproductive health (RH) voucher program’s causal effect on quality of care by exploiting group-level differences between voucher-accredited and non-accredited facilities in 2010 and 2012. Participation in the voucher scheme since 2006 significantly improves overall quality of postnatal care by 39% (p=0.02), where quality is defined as the observable processes or components of service provision that occur during a PNC consultation. Program participation since phase I is estimated to improve the quality of observed maternal postnatal care by 86% (p=0.02), with the largest quality improvements in counseling on family planning methods (IRR 5.0; p=0.01) and return to fertility (IRR 2.6; p=0.01). Despite improvements in maternal aspects of PNC, we find a high proportion of mothers who seek PNC are not being checked by any provider after delivery. Additional strategies will be necessary to standardize provision of packaged postnatal interventions to both mother and newborn. This study addresses an important gap in the existing RH literature by using a strong evaluation design to assess RH voucher program effectiveness on quality improvement.

Accessibility of long-term family planning methods: a comparison study between Output Based Approach (OBA) clients verses non-OBA clients in the voucher supported facilities in Kenya

“…Since vouchers schemes subsidizes on LTFP methods at voucher facility, it is expected that there is an increased supply of the methods within the facility and thus healthcare providers providing such services to OBA clients. The results are congruent to a study done in Kenya which showed that there may have been an increased utilization in family planning and thus spillover effect as a result of stocking contraceptive methods within the facilities [17]. …”

“…Overall, the total utilization of LTFP method among OBA clients is significantly higher compared to Non OBA clients. The findings are supported by a study done in Kenya which showed that increased utilization amongst OBA clients may have been due to increased family planning advice by the health care providers in the OBA facilities [17]. Since vouchers schemes subsidizes on LTFP methods at voucher facility, it is expected that there is an increased supply of the methods within the facility and thus healthcare providers providing such services to OBA clients.…”

“…For example; researchers have assessed the population level impact of vouchers on health facility delivery [15] and evaluated the community level impact of vouchers service utilization which showed that the voucher scheme helped in reducing the proportion of women in the community who paid out-of- pocket for safe motherhood services [16] Additionally, the quasi experimental evaluation of the voucher scheme showed the group level causal relationship between expansions of the Kenyan voucher mechanism and changes in the quality of post natal care [17]. On the other hand, other researcher have described the community experiences and perception of the clients on the voucher schemes [18] and a longitudinal analysis on facility based delivery in slums [19].…”

Enhancing the capacity and effectiveness of community health volunteers to improve maternal, newborn and child health: Experience from Kenya

“…quality of PNC at facilities 21,22 may have prompted women to leave facilities sooner than the recommended 48-hour stay. Our results are consistent with the poor utilization of PNC reported globally.…”

Providing safe motherhood services to underserved and neglected populations in Yemen: the case for vouchers

“…Some more recent evidence points to improvements in both the quantity and quality of care provided by voucher service providers (Watt et al 2015;Kanya 2013).…”