There is increasing global concern regarding gender-based violence (GBV) as a public health issue. Worldwide, the estimated lifetime prevalence of GBV among women is between 15 and 71 percent [1–4]. Estimates from African countries indicate a lifetime prevalence of between 25% and 48% (for example: 48% in Zambia, 47% in Kenya, 34% in Egypt, 30% in Uganda and 25% in South Africa) and an annual prevalence ranging between 10% and 26% [5–7]. Rape and domestic violence are estimated to account for between 5 and 10 percent of healthy years lost by women .
Data from Kenya, for example, show that 39 percent of women aged 15–49 years have experienced some form of physical violence from the age of 15 while 45 percent have experienced either physical or sexual violence . Among ever married women aged 15–49 years, 47 percent have experienced physical, sexual or emotional violence from a husband or live-in partner . Over the years, the need to improve access for survivors of GBV services in sub-Saharan Africa (SSA) has received increased attention, given the reported linkage between GBV and reproductive health problems [10–14]. GBV has, for instance, been associated with short birth intervals, increased infant mortality, under nutrition among children of abused mothers, and increased incidence of HIV/AIDS and sexually transmitted infections (STIs) [13, 15–19].
The high rates and health effects of GBV documented in SSA have led to discussions and proposals for the integration of GBV services in innovative health financing models such as the “demand-side” health financing (DSF) or “output-based aid” (OBA). The goal of these health care financing models is to increase access to and uptake of key services by offering sufficient subsidies and resources to enable the user to purchase the service, preferably by being able to choose a provider from among a number of alternatives [20, 21].
In OBA programs, a voucher management agency (VMA) distributes or sells vouchers at a subsidized price to clients, who purchase a voucher for a specific service. OBA programs provide incentives to clients and healthcare workers and subsidize specific health care packages based on the provision of care with pre-defined quality standards and pre-determined outputs [22, 23] with the goals of improving service quality, stimulating client use of selected services, targeting services among high-priority populations (such as the poor or underserved), and containing costs [24–28]. In some programs there is a supervisory or regulatory body that meets periodically to oversee their functioning. The structure of the OBA programs is such that it identifies and invites individual or networked service providers (public, non-profit or for-profit) to assess their suitability to participate. Those agreeing to participate can only do so if they can demonstrate service provision at a specified standard of quality of care; they are then accredited to participate subject to regular review. Usually a number of providers are accredited to create competition and give consumers choice. When the client needs the services, s/he then redeems the voucher for the specified service at one of the accredited facilities. The provider is then reimbursed service cost or paid an incentive upon submission of a claim and supporting evidence to the VMA.
In Kenya, the reproductive health voucher program was launched in 2005 with an overall aim of increasing skilled birth attendance for women seeking maternal and newborn services, increasing utilization of long-term family planning methods, and increasing the uptake of gender-based violence recovery (GBVR) services for both men and women. The program contracts both public and private facilities to provide a comprehensive reproductive health service package . The OBA program is currently being implemented in five sites across five provinces in Kenya namely: Kisumu, Kitui, Kiambu, and Kilifi districts, and Korogocho and Viwandani informal settlements in Nairobi. In total 10 hospitals were accredited to provide GBVR services.
The GBVR services vouchers are made freely available to women at the facility; there is no community-based distribution and no specific selection criteria for identifying eligible clients, such as a poverty grading tool used to identify beneficiaries for family planning and safe motherhood services . Each accredited facility has a stack of vouchers which is used to submit a claim after services are rendered to clients. The GBVR services vouchers provide access to a wide range of services, including: (i) a medical examination, treatment and management of injuries, hospitalization and accommodation, laboratory testing and X-rays, pregnancy prevention services and HIV post exposure prophylaxis (PEP), (ii) counseling services specifically consisting of psychological care, trauma counseling, crises management, HIV pre-and post-test counseling, and adherence counseling, and (iii) links to support groups which provide legal aid, monthly group therapy sessions for survivors of rape, information and referral for long-term shelters, and help for survivors in liaising with social services departments and private sector support for medical services.
Although the voucher program has been successful in increasing skilled birth attendance, uptake of long-acting family planning methods, and reducing out-of-pocket expenditure [30, 31], there is no evidence to date regarding the effectiveness of the voucher approach with respect to improving access to GBVR services. This paper therefore explores the extent to which the Kenya OBA GBVR services are viewed as effective from the perspectives of different actors including any perceived barriers to the use of GBVR services.