Many poor women face huge financial barriers that limit their access to quality maternal and reproductive health care . Out-of-pocket costs arising from birth complications can be prohibitive or catastrophic, thereby excluding many mothers from receiving necessary care or pushing families further into poverty . Experience has shown that routine financing of health inputs such as staff costs, equipment and buildings without associating these inputs with the services (outputs) delivered does not necessarily enable access to quality services among the poor [3–5]. To overcome this challenge, alternative financing mechanisms have been designed that transfer purchasing power to the consumer of health services, thereby motivating providers to offer more accessible and higher quality services so that they can attract and serve consumers who purchase their services [6–8].
One such financing mechanism is the output-based aid (OBA), which targets the poor and under-served populations with subsidized essential health services [5, 9]. In OBA voucher programs, a voucher management agency (VMA) distributes or sells vouchers for specific services at a subsidized price to intended beneficiaries, and then reimburses healthcare facilities for providing services to clients presenting with vouchers. OBA programs subsidize specific health care packages based on provision of care with pre-defined quality standards [6, 10, 11]. Most OBA programs have the following goals: to improve service quality, to stimulate client use of selected services, to target services among high-priority populations where service uptake is low in the absence of the subsidy, and to contain costs [12–16]. Most OBA programs have a supervisory or regulatory body that meets periodically to oversee their operations including contracts with providers. OBA programs invite service providers (public, non-profit or private-for-profit) to participate. Those agreeing to participate can only do so if they demonstrate service provision at a specified standard of quality of care. Usually a number of providers are accredited to create competition and give consumers choice.
In Kenya, the reproductive health (RH) vouchers program has been implemented by the Government since 2006 with major funding from the German Development Bank (KfW). Details of the implementation process are discussed elsewhere . The program aims to improve utilization of selected services among economically disadvantaged women of reproductive age (15-49 years) in four districts (Kitui, Kiambu, Kilifi, and Kisumu), and two informal settlements in Nairobi (Korogocho and Viwandani). The program offers three packages of reproductive health care services: (1) safe motherhood (SM) including up to four antenatal care visits, delivery (normal or Caesarean) and complications as well as one postnatal care visit within six weeks post-delivery; (2) long-term family planning (FP) methods (implants, intra-uterine contraceptive device [IUCD], and voluntary tubal ligation); and (3) gender-based violence recovery services (GBVRS) including medical examination, treatment and counseling.
Potential beneficiaries for the SM and FP vouchers are identified in the community by voucher distributors appointed by the VMA using a poverty grading tool consisting of eight items including housing, access to health, water sources, sanitation, daily income and meals per day. Those scoring between 8 and 16 points on the poverty grading tool qualify to purchase the vouchers from the distributors at a subsidized price equivalent to US $2.50 for SM and US $1.25 for FP vouchers. They then redeem the vouchers for services at accredited facilities that comprise public, private-for-profit and private-not-for-profit providers. The GBVRS voucher is, on the other hand, freely available at accredited facilities to all those who are in need of the services regardless of socio-economic status; this voucher functions primarily as a means for the provider to recover the costs of the GBVR services and for ensuring that quality of care is maintained through accreditation. The distributors are, however, expected to sensitize community members about the availability of the voucher.
The voucher program was conceptualized in the context of poor reproductive health indicators in the country. For instance, at the time of the program’s inception, the maternal mortality ratio was 414 deaths per 100,000 live births while infant mortality rate was 77 deaths per 1,000 live births . In addition, although 88% of expectant women received antenatal care from a trained service provider, only 40% of the births were delivered in a health facility while 42% of the births were delivered under the supervision of a health professional . Moreover, births to women from the poorest households were more than four times less likely to be delivered in a health facility or under skilled care compared to those to women from the richest households (16% and 74% respectively for health facility delivery and 17% and 74% respectively for skilled delivery care, . In addition, the contraceptive prevalence rate had stagnated at 39% since 1998, unmet need for family planning was 25% while women desired fewer children than they actually gave birth to (average of 3.9 children desired compared to the total fertility rate of 4.9 children per woman .
Several evaluations of output-based financing schemes for RH services have demonstrated some positive effects of the programs with respect to increased use of skilled birth attendance, hospital deliveries, antenatal care, family planning, health counseling, and sexually transmitted infections (STI) services as well as reduction of inequality to health care access, improvements in quality of services, and reduction in out-of-pocket expenditure [10, 15, 16, 19–23]. There has, however, been little documentation of community perceptions of and experiences with accessing and using reproductive health vouchers. In addition, although studies of voucher programs generally find associations with improved outcomes, larger contextual issues and the experiences of potential or actual beneficiaries are often unexplored. This paper uses a mixed-methods approach to examine community experiences and perceptions of the OBA voucher program in Kenya. Understanding the community needs and preferences in the context of health care interventions enables the alignment of policy and programs to public expectations and can thus determine the success of the programs.