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8/8/2019 Vouchers for health: Increasing utilization of facility-based family planning and safe motherhood services in Kenya
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P4PC
aseStudies
Vouchers for health:IncreasIng utIlIzatIonof facIlIty-based famIlyPlannIng and safe
motherhood serVIcesIn Kenya
This case study describes a Kenyan demand- and supply- side pay-for-performance (P4P) scheme that uses vouchers as a means to reduce
maternal and child mortality. Subsidized vouchers are targeted to poor
women, enabling increased access to a range of safe motherhood and
family planning services. Accredited public and private health service
providers are reimbursed for voucher-supported services provided.
Findings show that uptake of safe motherhood vouchers was very
successful; however uptake of family planning vouchers proved more
complex. This case study provides an example of a Government-led
program to increase service utilization and offers lessons for countries
considering implementing similar voucher-driven schemes.
B Bllws, Mahw Hamil, a Fracis K
nside
Ab h P4P CasSis Sris2
Acrms 2
rci3
Backgr 5
Prgram Srcr
a Maagm 9
Prgram Impac 17
mmar 22
Ackwlgms 26
Rfrcs 27
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2 P4P Case Studies - Kenya
ABout tHe P4P CASe StudIeS SeRIeS
Pa-fr-prfrmac (P4P) is a srag ha liks pam rsls. Halh scr sakhlrs, frm iraial rs
gvrm a halh ssm plicmakrs, prgram maagrs,a halh car prvirs icrasigl s P4P as a impra
cmplm ivsig i ips sch as biligs, rgs, a
raiig wh wrkig srgh halh ssms a achiv
h Millim dvlpm Gals (MdGs) a hr args
ha rprs br halh sas fr ppl. B prviig
fiacial icivs ha crag wrk war agr-p
rsls, P4P hlps slv challgs sch as icrasig h qali
f, as wll as accss a s f halh srvics.
Ma vlpig cris ar pilig r scalig p P4P
prgrams m MdGs a hr halh iicars. each
crs xpric wih P4P is iffr, b b sharig
apprachs a lsss lar, all sakhlrs will br
rsa h prcsss a challgs ivlv i P4P
prgram sig, implmai, valai, a scal-p.
this Halh Ssm 20/20 cas s sris, which prfils
maral a chil halh-ri P4P prgrams i cris
i Africa, Asia, a h Amricas, is i hlp hs
cris a rs alra gag i P4P fi- hir
prgrams a hs ha ar cmplaig P4P ap scha prgram as par f hir ffrs srgh hir halh
ssm a imprv halh cms.
Ax ach cas s ar ls ha h cr s i is
P4P prgram. th axs appar i h lcric vrsis
(Cd-RoM a Halh Ssms 20/20 wb si) f h cas s.
Ra eichlr, Ph.d
tchical Avisr, Pa fr Prfrmac
Halh Ssms 20/20 Prjc
ACRonyMSAnC Aaal Car
BtL Bilaral tbal Ligai
FBo Faih-bas orgaizai
FP Famil Plaig
GVR Gr-bas Vilc Rcvr
IGeS Isi fr Gshis Szialfrschg GmbH (Isifr Halh a Scial Rsarch,L.)
IuCd Irari Cracpiv dvic
KdHS Ka dmgraphic a HalhSrv
KfW Grma dvlpm Bak
KMet Ka Mical a ecaialtrs
MoH Ka Miisr f Halh
MtR Mirm Rviw
nCAPd naial Criaig Agc frPplai a dvlpm
nGo ngvrmal orgaizai
nHIF naial Hspial Israc FoBA op-bas Apprach
PnC Psaal Car
PwC PricwarhsCprs
SdP Srvic dlivr Pi
SM Saf Mhrh
tFR tal Frili Ra
VMA Vchr Maagm Agc
VSP Vchr Srvic Prvir
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3 P4P Case Studies - Kenya
IntroductIon
this cas s cms a vl halh fiac irvi i Kaha ss vchrs a irc rimbrsm rsrcr icivs
amg pais a halh car prvirs. th vchr givs pais a
larg, prabl cmic sbsi ha h ca ak a accri
facili fr priaal srvics, iclig facili-bas livris a lg-
rm famil plaig (FP) prcs. Prvirs ar rimbrs fr raig
vchr-barig pais accrig a cracall agr saarf car. I h firs w ars f h prgram (J 2006ocbr
2008), mr ha 60,000 wm livr sig h Saf Mhrh
(SM) vchr a h prpri f mrgc bsric srgris
icras ramaicall a crac faciliis. Mr ha 10,000 wm
s h FP vchr accss lg-rm mhs (msl irari
cracpiv vics a bal ligais) frm qalifi mical
prfssials.
th vchr prgram was lach i J 2006 wih 54 crac
pblic, priva, a -prfi prvirs. th iiial prgram arg
hr rral isrics a w rba slms rprsig a al pplai
A man brings his newborn to a clinic to
receive postnatal care services offered
through the Safe Motherhood Voucher (SM).
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4 P4P Case Studies - Kenya
f mr ha 3 milli. B ocbr 2008, h prgram ha ra mr
ha 60,000 xpca mhrs a 10,000 iivials skig lg-
rm FP mhs. A sc phas is pla bgi i 2010 wih a
xpa packag f srvics a aiial prvirs i h sam pil
aras.
thr spara vchrs wr vlp ffr : 1) aaal car,
facili-bas livris, a psaal car; 2) mr mhs f
lg rm FP; a 3) gr-bas vilc rcvr (GVR) car.
Alhgh a pplai impac valai was cc i Phas I
(a cmprhsiv valai is big carri i Phas II), vchr
claims aa a faciliis mhl ilizai figrs prvi sm isigh
i pai vlm rig h iiial prjc pri. th Ka vchr
prgram was sccssfl i icrasig facili ilizai, pariclarl wih
rspc h SM prgram. Hwvr, giv h aial fr FP,
icrasig ilizai f h FP srvics i Phas II will b a sigifica
gal f h vchr maagm am.
this cas s f h Ka vchr prgram is bas pblish
rprs, prsal cmmicais, a iral cms ma
availabl h ahrs. Prvis cms prvi sfl backgr
a isighs i h rigis f h prgram a wr wri b
xprs i h Ka Miisr
f Halh (MoH); h naial
Criaig Agc fr Pplai
a dvlpm (nCAPd) a hMiisr f Plaig a naial
dvlpm; cslas frm
h Grma Isi fr Halh
a Scial Rsarch L. (Institut
fr Gesundheits und Sozialforschung
GmbH, IGeS); h Bill & Mlia
Gas Fai; Famil Halh
Iraial a h Pplai
Ccil.
The SM Voucher allowed this mother
to seek proper pre- and post- natal
care.
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5 P4P Case Studies - Kenya
MAteRnAL MoRtALIty And
FAMILy PLAnnInG In KenyA
th Ka halh car ssm is i a ssai crisis, vi ipr pplai halh cms a rilizai f xisig
faciliis. Rprciv halh srvics ar a barmr f halh ssm
prfrmac a ar a sigifica firs pi f cac fr h majrif al wm i h cr. Alhgh a high prcag (mr ha
80 prc) f prga wm sk aaal car (AnC), fwr ha
half livr i a halh facili, ma bcas h ca affr h css
f srvic r raspr, r ar iscrag b h lw srvic qali.
Ka saw a ssai a rlaivl imprssiv fall i h al frili
ra (tFR) frm 8.1 (197578) 4.7 (199597); hwvr, accrig
h 2003 Ka dmgraphic a Halh Srv (KdHS), h icrass
i cracpiv prvalc sall a 39 prc (19982003) a
h tFR rs 4.9 i 2003 (Cral Bra f Saisics al. 2004).
ths prcags ar sigifica i a grwig pplai, a Kaspplai grw rghl 25 prc bw 2000 a 2008. A prs,
hr ar apprximal 8 milli wm ag 1549 ars, a his
mbr will grw 10.5 milli r mr b 2015. th 2003 KdHS
sima h mia ag a firs marriag b 17 ars fr wm
wih cai, a 19 ars fr wm wih a primar cai.
Fr-fr prc f crrl marri wm wa mr chilr
a 79 prc f wm wih six r mr chilr wa mr.
bacKground
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6 P4P Case Studies - Kenya
y h prvalc f vlar srilizai, irari cracpiv
vic (IuCd), a ral cracpiv s is fallig, whil h s
f lg-acig hrmal mhs has ris slighl, kpig vrall
prvalc f mr FP s csa a 31 prc.
daa maral halh iicars i Ka ar pr. Rc aial
srvs hav sima ha 414 wm i frm chilbirh-rla
cass pr 100,000 liv birhs (KdHS 2003). ua livr is
f h gras risk facrs fr maral mrali a mrbii (Gill
al. 2007). of birhs rpr i h 2003 KdHS, l 40 prc wr
livr i a halh facili. th lack f rai mical assisac rig
livr jparizs h livs f bh mhr a wbr. unICeF
sima ha hr ar 80 ifa ahs (r 1 ar l) pr 1,000
liv birhs a 121 ahs f chilr r 5 ars f ag pr 1,000 liv
birhs (unICeF 2007). Lw cracpiv s a h crrla high
tFR rsls i iaqa birh spacig, which cribs maral
mrali a ls prcivi as g wm ar pll awa frm
caial ppriis a cmic acivi a a arl ag.
Giv h rapi grwh i h mbr f fril wm a h ris
i h tFR, i is pssibl ha lss w sragis ar ap, mr
Ka wm will i frm prgac, chilbirh, a saf abri
i h cmig ca ha i a prir 10-ar pri i h hisr f
h cr. Fr vr wma wh is i chilbirh, p 20 wm
sffr mrbiiis, f wih svr mical a scial csqcs.
Wih accss srgical rpair, a faal fisla ca lav a wmaici, which smims rsls i abam b hr hsba
a famil (Vlz al., 2007). Ifrili ca hav similar csqcs.
Gr-bas vilc agais wm als is a sigifica prblm i
Ka. th 2003 KdHS f high prpris f marri wm a
ivrc r spara wm xpric iffr frms f vilc
b hir crr r las hsbas. th ms cmm frm f spsal
vilc was slappig r arm wisig, which ha b xpric b
-hir f wm. th KdHS f ha 23 prc f vr-marri
wm ha vr b psh, shak, r hrw b a hsba; 17
prc ha b pch; a 11 prc ha b kick r ragg.
th KdHS ccl ha marial rap appar b cmm, wih
15 prc f marri wm a spara r ivrc wm
rprig havig xpric frc sxal ircrs; 12 prc
rpr his xpric i h 12 mhs prcig h srv (KdHS
2003).
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7 P4P Case Studies - Kenya
deVeLoPMent And LAunCH oF
tHe VouCHeR PRoGRAM
t arss hs maral halh a gr vilc pririis, h
Grma dvlpm Bak (KfW) prvi sppr fr a vchrprgram sbsiiz saf mhrh, FP, a GVR srvics. Plaig
h vchr srvics k svral ars frm ccp prgram
lach. Iiial cslais k plac i la 2003. A chical assisac
missi Ka i arl 2004 brgh ghr parrs frm h
gvrm f Ka, rs, gvrmal rgaizais (nGos),
a faih-bas rgaizais (FBos) i a wrkshp whr h vchr
ccp was irc a iscss. Aciv sakhlrs i h
vchr prgram ccpalizai icl KfW, h Africa Pplai
a Halh Rsarch Cr, h Ka Gvrm divisi f
Rprciv Halh, h nCAPd, h Ka Mical a ecaialtrs, h MoH, h naial Hspial Israc F (nHIF), h
Pplai Ccil, PricwarhsCprs (PwC), a srvic
prvirs.
th rsls f h 2004 chical missi wr prs
i a fasibili rpr h rs a nCAPd ha
prs pis a rcmmais fr h sig,
css, a rgaizaial srcr f h prps
vchr prgram (Griffih al. 2004). th rpr als
prs rcmmais ivsms i ifrmai
ssms, fiacial ssms, capaci vlpm, markig
sragis, a valai capabiliis. Cs simas wr
als icl, b mifi as plas wr clarifi i 2005
a 2006.
evs wihi Ka a h im hlp riv h
vchr aga. Parliam was csirig lgislai
cra a aial scial halh israc f a
h vchr ccp was viw b sm Ka
plicmakrs as a sfl ml fr crac srvics
a prvir rimbrsm. th Miisr f Plaig anaial dvlpm, hrgh h nCAPd, als s
gai sigifica xpric giv is k rl i h sig
a implmai f h vchr prgram.
I 2005, h gvrm f Ka mbark a
prfrmac-bas rprciv halh prgram
Through the FP Voucher, women can
receive FP counseling and services
at local providers participating in the
voucher scheme.
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8 P4P Case Studies - Kenya
iciviz accss wms rprciv halh car. th
gvrm rmi ha piall ffciv mas imprv
rprciv halh cms was mpwr pais wih a vchr
accss car frm apprv prvirs wh wl b rimbrs a
pr-pai basis. I vlp a sigl prgram wih spara vchrsfr FP a SM srvics, h lar f which icl aaal car a
accss a qalifi halh wrkr rig livr. A hir vchr
allw clis accss GVR srvics iiiall frm nairbi Wms
Hspial; lar his was x hr accri hspials i h
prjc aras. th vchr srvics wr lach i J 2006 b h
nCAPd i h rral isrics f Kism, Kii, a Kiamb, as wll as
h nairbi ifrmal slms f Viwaai a Krgch. tghr,
hs aras hav a al pplai f apprximal 3 milli.
drig h plaig sag, aspcs f prgram sig a vchr
pai pplais rw sigifica chags. Iiial pial
prgram bficiaris rag acrss svral high-priri pplais
frm xpca mhrs m a wm skig FP srvics
iivials skig HIV cslig a sig. th cisi
prvi crac SM srvics lw-icm wm was ma afr
rviwig pimilgic aa iif m a afr cslig
sakhlrs rmi if h cmbiai f vchrs a cracs
wl b a sfl lvr rc maral mrbii a mrali.
th SM vchr as fiall implm ils h sr fr
AnC visis, a livr visi, a psaal car (PnC) wihi sixwks afr livr a a crac facili. Cmplica livris,
ha fr xampl ra xcssiv bl lss r prvi srgr, ar
rimbrs a ab fr ims h ra fr rmal livris ($292
vrss $70). PnC s crrl icl malaria prphlaxis, b
s ivlv basic vacciai fr h ifa.
th FP vchr ils h sr a
f svral mr cracpiv mhs:
bilaral bal ligai (BtL), vascm,
hrm-bas implas, a IuCds. th
GVR vchr ils h sr micalxamiai, ram, a cslig.
th SM a FP vchrs ar availabl frm
crac vchr isribrs praig i
siga pblic vs. th GVR vchr is
isrib l a crac faciliis rahr
ha a hir-par isribrs, h
pricabili f h v.
Facilities were selected to participate i
the voucher scheme as voucher service
providers if they could demonstrate th
their staff was qualified and competent
the delivery of healthcare services.
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9 P4P Case Studies - Kenya
PRoGRAM MAnAGeMent
Figr 1 scribs h rgaizaial srcr f h vchr prgrami rms f majr fcis a h acrs rspsibl. As is am
implis, h vchr maagm agc (VMA) is h rgaizai
rspsibl fr maagig h vchr prgram vrall. I Ka, VMA
fcis wr iiiall ivi bw h fiacial srvics cmpa
PwC a h -prfi Pplai Ccil, which wrks iraiall
isss ar pplai a rprciv halh. th nHIF was
chs pla a rl prviig accriai a qali assrac
srvics, which wl crib h mirig a valai
b PwC.
Program structureand management
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PRoVIdeR SeLeCtIon And ACCRedItAtIon
Fif-fr halh faciliis wr crac as vchr srvic prvirs
(VSPs), a h nGo Mari Sps Ka prvi rach FP srvics
i all h prjc sis. Facili paricipai vari b rgi a p fprvir (tabl 1). Lss ha 40 prc f h VSPs wr gvrm
faciliis.
table 1: DistributiOn OF COntraCteD
FaCilities by lOCatiOn anD tyPe OF PrOViDer,
OCtOber 2007
s Pc Pv FbO ngO to
Kism 7 6 3 2 18
Kiamb 11 3 3 0 17
Kii 1 2 4 0 7
nairbi 2 8 0 2 12
tal 21 19 10 4 54
th nHIF maag VSP accriai. Iiiall, ma faciliis wr
crac wih h aim f spprig cmpii a pai chic,
a wih h rsaig ha hir srvic qali wl imprv
vr im. th i was cliva capaci a xpric amg
prvirs a wihi h nHIF, which wl il bfis b h
scp f h vchr prgram.
Accri faciliis ha m h saffig a ifrasrcrrqirms f h vchr prgram. th faciliis wr xpc
hav prprl rai saff wh m aial prfssial saars. All
phsicias, rss, miwivs, pharmaciss, a pblic halh prfssials
ha b rgisr wih hir apprpria prfssial halh ccils,
.g., Ka Mical a dal Praciirs Bar a th nrsig
Ccil. th rgisrai f halh car prvirs a faciliis is
cmplsr (Griffih 2004). I aii, h -gvrmal halh
faciliis acqir a Srvic dlivr Pi (SdP) mbr
frm h MoH s ha h cl rciv gvrm-prvi rgs,
vaccis, a hr mical spplis which h wr il as VSPs.
th mirm rviw (MtR) f h vchr prgram (Mai al. 2008)
f facili praig wih a SdP mbr, which ma ha
i cl rciv vaccis a cracpivs ircl frm h MoH.
Csql, ifas br a his facili ha b rfrr lswhr
fr h BCG vacci fr brclsis. (th Wrl Halh orgaizai
rcmms BCG fr all wbrs i tB-mic aras [Rkha a
Swamiaha 2007]).
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StAndARd oF CARe
Alhgh ri nHIF rviws f facili cmpliac wih h saars
f car wr b s as a basis fr rwig VSP aal cracs,
his was vr implm. As abv, h Pplai Ccilvlp a maal ailig, b prcr, h saars f car a
prviig sampl qali mirig ls (Warr al. 2006) ha wr
hav b s i Phas 1 f h vchr prgram. th ahrs f
his cas s rviw h fllwig ls:
z Accriai Maal
z Criria fr Vchr Srvic Prvir Slci
z Qali Assrac Mhl Mirig evalai tl
z
Qarrl Qali Rviw tl
z Qarrl Sppr Sprvisr tl
z Mhl Cli exi evalai Frm
Alhgh h facili saar-f-car rviws i ak plac, h
qali f halh car prvisi i pblic faciliis cl b srgh
hrgh priic raiig bs pracics h MoH givs all pblic
prvirs (i a f h vchr prgram) priic raiig ha ca
hlp hm ar ciig mical cai (CMe) cris.
Fr priva prvirs i h vchr prgram, hwvr, hr wasihr CMe ppri r rglar facili rviw. th MtR f
priva vchr facili wih implas i sck b saff rai
isr hm, alhgh isri is a
mir srgical prcr. A sli
ha sms appar maa mr
raiig is wih prblms: ri
mical raiig has clar cs implicais
fr priva VSPs. Allwig saff a
raiig mas ha h facili will hav
pra wih ha prs/s r g ashr-rm rplacm, a aiial cs.
t crag hs faciliis sppr
saff raiig, h ms b cvic ha
h br-rai saff will hac lg-
rm prcivi (a srvic qali),
wighig h shr-rm cs f raiig.
The SM Voucher helps combat
economic barriers preventing Kenyan
women from receiving safe delivery
services and postnatal care.
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13 P4P Case Studies - Kenya
PwC scr claim frms fr cmplss a mical lgic. (S h
claim frm i h Ax A) th claims cl hav prvi a prspciv
h faciliis saar f car. I was clar h ahrs,
hwvr, ha h claims wr masr agais a xplici qali
args r ha hr was v sffici ifrmai rpr hclaims frms masr aspcs f halh car qali.
Alhgh h MtR i iif h prcag f -cmplia
faciliis, i i iif a rag f prblms cr b VSPs rig
cmpl wih h saar f car. of h iaqa pracic was
h rsl f shrcs ak maximiz rimbrsm rv. th
MtR rcmm h s f maagm safgars avi facili
vrcrwig, rs f spplis sch as glvs, a ischarg bfr
pai is ra (Mai al. 2008).
PRICInG And ReIMBuRSeMent
VSPs f all ps pblic, priva, nGo, a FBo rciv p
h maximm rimbrsm ras shw i tabl 2. Ras wr
gia wih ach facili bfr h facili was crac. Grall,
gvrm faciliis wr rimbrs a a lwr ra ha priva s,
bcas h gvrm cvrs majr xpss (saff im a spplis)
i pblic faciliis sparal. ulik i h ugaa vchr prgram, h
Ka vchr prgram cl mak vchr rimbrsms ircl
h VSP, rahr ha h isric halh ffic (Bllws a Hamil
2009).
table 2: maximum reimbursement rates by
serViCe FOr sm, FP, anD gVr VOuChers
Rates for SM services include KSh 1,000 for 4 antenatal visits, about US$3.50
per visit.
Voc vc Ks us$
SM: nrmal livr 5,000 $70
SM: C-sci r hr cmplica livr 21,000 $292
FP: BtL a vascm 3,000 $42
FP: Impla 2,000 $28
FP: IuCd 1,000 $14
GVR Fll cs Fll cs
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14 P4P Case Studies - Kenya
th pical rar im fr rimbrsm was 30 as. narl
all priva a FBo prvirs xprss saisfaci wih h sp f
claims prcssig a rimbrsm. n srprisigl, pblic a FBo
faciliis wr vr hsiasic ab h prgram as i rprs
aiial rv abv wha h rciv frm gvrm ars, whras priva prvirs wr mr irs i imprvig
h rimbrsm ams.
Bh h srvic css a fs charg b prvirs vari fr
-vchr pais, accrig a slci f prvir ccrs
pblish i h MtR (Mai al. 2008). this variai was gras fr
C-scis, fr which prvirs charg KSh 12,00030,000 fr -
vchr pais; h vchr prgram rimbrsm fr his srvic
was KSh 21,000. A fw priva prvirs rpr ha hir css fr
cmplica livris xc h rimbrsm am. ohr
prvirs, spciall pblic cliics, wr sr f hir css, a
sbsql h VMA assis hm wih fiacial rcr kpig.
Sm prvirs rpr ha a larg mbr f h claims h
sbmi, i sm cass mr ha a qarr, wr rjc bcas f
icrrc r icmpl ifrmai h claim frm (Mai al. 2008).
ovrall, h vchr prgram sms b havig a psiiv capaci-
bilig ffc i rms f familiarizig prvirs wih h prcss f
rimbrsm a rackig hir xpirs.
ReACHInG uSeRS
Avrisig agc Lw Scaa was crac mark h
vchrs. Markig mhs icl mlimia prsais
a pblic migs, rligis cgrgais, a mark as. Rai
avrisms wr s, b spcific aa ar availabl cvrag
r h mbr f rai sps. Bra imags, slgas, a pri
marials wr vlp. Figr 2 shws prmial psrs fr h
SM a FP srvics.
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Figure 2: POsters FOr saFe mOtherhOOD anD
Family Planning serViCes
PwC sig a pri h vchrs, which wr giv vchr
isribrs. disribrs iifi pr wm i f rprciv
halh srvics a piall ligibl fr vchrs. t rmi
ligibili, h s a pvr graig l (s Ax B) vlp b
MSK ha masr pvr accrig lcall maigfl ccps
lik mbr f mals pr a a hm bilig marials. If h wm
wr f ligibl, h wr allw b a vchr frm h
isribr a h prics f KSh 200 fr h SM vchr a KSh 100 fr
h FP vchr.
Prir h 2006 lach f h vchr prgram, cmmi grps
wr prps as g vchr isribrs. yh a wms grpswr crag sll vchrs prga wm a iivials
skig lg-rm FP pis. As h prgram prgrss i 2007, h
ml appar wrk wll i Kism a Kii isrics b imprpr
r fral vchr sals wr rprl cmm i h nairbi
slms a Kiamb isric. (Spcific mbrs ar availabl.) Vchr
isribrs i h lar aras cmp sll vchrs bcas
h ar a cmmissi vr sal. oc nCAPd iifi h
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lakag, isribr rimbrsm was chag a fix mhl
salar a aal salar b rw if sigifica mbrs f
sal sals wr bsrv. Sp-chcks wr cc a a sampl
f pais hms cfirm ha h pais qalifi as lw icm.
Sch chcks iscrag wispra imprpr sals b rqir aabili fllw p a lca pais, which is cs ffciv a
sfficil larg scal prv all sch cass.
Pais ra vchrs fr srvics a crac prvir faciliis, a
prvirs sbmi claim frms h VMA fr rimbrsm. As
abv, h rimbrsm prcss sall aks ab 30 as frm h
a f sbmissi.
thr ar w aiial pis ab vchr isribi b :
th GVR vchr is fr f charg a, as wih h hr srvics,h prvir is rimbrs prvisl gia ras. this was
maximiz h iciv fr pial clis sk, a VSPs prvi
car. GVR srvic clis f fl sham a cfr a gra al
f scial sigma, v i halh car faciliis, i a halh ssm ha is
largl rspsiv gr vilc. Fwr ha 400 claims hav
b sbmi fr his srvic.
Prchas f h FP vchr is a impra iicai ha h pai
is xrcisig chic sk lg-rm birh crl. Hwvr, hr
is sm ccr i plicmakr a glbal rprciv halh circls
ha gvrm-f FP icivs cmpl pais i chics
h ma rgr. Chargig fr
h vchr is csir
a impra sigal ha h
pai is makig h cisi
frl a is sr ab sig
h srvic.
Local voucher distributors
assess voucher eligibility based
on a poverty grading tool.
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Wh valaig h impac f a vchr prgram, fiv cagris fcms cmml ar csir: pai a prvir kwlg,
srvic qali, facili ilizai, srvic xpirs, a isas
br (prvalc r icic). ths cms ar grall
masr a ihr h facili lvl r, lss cmml, i h gral
pplai, a cmpariss ma bw grps ha rciv h
irvi a similar grps ha i rciv h irvi.
th aa frm h Ka vchr prgram allw fr makig a
pplai impac assssm. Hwvr, a rrspciv facili-lvl
valai is pssibl as PwC has ril cllc facili aa frm
VSPs a pvr scrig irviws b vchr isribrs.
th nCAPd has als rcr vchr a -vchr maral
livris a crac cliics a ca cmpar vchr a -
vchr ilizai rs vr im.
I aii impac valai, prgram maagrs cl s his
grs am f facili aa imprv mirig f prgram
srvic qali a cs ffcivss. Fr xampl, cmbiig -
vchr ilizai wih kw facili css fr -vchr livris
prvis a cs--p rai ha cl h b ircl cmpar
wih vchr livr css.
Pplai impac assssm grall rqirs aa cllc si
f ri vchr prgram prais. I 2006, h nCAPd crac
Program ImPact
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Voc
vc
no-voc Voc t s
SM livris, all 67,259 60,581 51,000 78,635FP, all 5,973 11,296 62,000 25,620
BtL 774 3,954
Vascm 4 5
IuCd 1,805 594
Implas 3,390 6,743
GVR 337 1,000
Micr Cslas cc a basli srv a sig a
framwrk fr mirig a valai. Micr carri a rcrs
rviw a slc crac faciliis a ma rcmmais fr
imprv ifrmai maagm (Mwg a oik 2007). th
fr a pplai impac valai was clar i h plaig sags arcmm a ar i h prgram b h MtR am, b a
valai has b cc.
utILIZAtIon: IMPACt on PAtIentS
th 2004 SM vchr fasibili rpr prps a iiial arg f
100,000 livris i h firs w ars f h prgram. Hwvr, as
plaig prgrss, h fial pr-lach arg, bas h siz f
h sima KfW gra, a sima srvic livr a vrha
css, was rc 51,000 livris. oc h prgram bga,acal ilizai f h vchr far srpass his lwr arg a
spplmal fs wr pa fr h aiial livris.
th vchr prgram rachs sm pri f prga wm wh
prvisl i livr a faciliis bcas f cmic barrirs.
Hwvr, wm ci fac barrirs livrig i halh faciliis
fr xampl, a abrp s f labr a r lack f raspr ha
prv hm frm rachig a facili. th vchr prgram al ma
b gh vrcm h livrig a hm.
I cras h pplari f h SM vchr, ilizai f h FP
vchr srvics was lw; ha is, whil h FP vchr acc fr
rghl w-hirs f all FP srvics prvi a crac faciliis, h
s f FP mhs i gral rmai lwr ha aicipa. Icrasig
ilizai rmais a cral gal f h Ka vchr prgram.
table 3: utilizatiOn by serViCe,
June 2006OCtOber 2008
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Voucher and non-voucher actual patient volume, target patient volume, and voucher
sales, by service. The voucher program accounted for roughly half of all deliveries and
two-thirds of FP services among contracted facilities. However, FP utilization was much
lower than anticipated, and fewer than half of all FP vouchers sold had been used by
October 2008.
o impra ras fr h lw pak f FP vchrs ma b a
xaggra far f si ffcs f mr cracpi mhs. daa
frm h 2003 KdHS, prs i Figr 3, sppr his cclsi.
this implis a fr a srgr caial cmp h FP
vchr markig ffrs. ohr rass fr sig cracpi,
sch as prsal ppsii r rligis prhibii, migh als b
iflc hrgh markig.
Figure 3: maJOr reasOns nOt tO use a mODern
COntraCePtiVe methOD
The most important reasons for respondents under 30 not using modern
contraception are safety concerns, religions prohibition, personal opposition, and the
desire for more children. For respondents older than 30 years, there is less need as
well. Sourcing and access are not major issues for any age group.
Src: 2003 KdHS
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I h prsc f a vchr r hr ma-si sbsi, h firs
pais prchas h vchr ar hs whs ilizai has b
limi sll b cs r accss, a all vchr prgrams ca capr
hs pais. Fr hr pais, rilizai f a srvic ma
b riv b -cmic facrs sch as clral rms r fars fharmfl si ffcs. th aa i Figr 3 iica ha -cmic
facrs ma b rspsibl fr h limi pak f FP vchrs i h
arg pplai. Markig shl b sig arss hs -
cmic barrirs b likig h vchr bra a prcpi f saf.
CAPItALIZAtIon: IMPACt on PRoVIdeRS
Ma prvirs, lik Hrma nrsig Hm i nairbi a nma
Hspial i Kii, hav s h aiial rv frm vchr
pais xpa hir faciliis, prchas bs, b qipm agrars, a hir aiial saff. Sm faciliis hav xpa h
rag f srvics h ffr b isallig a simpl srgical har
hal prcrs ha prvisl ha b rfrr (Mai al. 2008).
I aii spprig h css f car a chic amg pais,
h vchr prgram has allw prvirs capializ mch mr
rapil ha h cl hav wih h prvis lvl f ma.
ths h vchr prgram sbsi, b bfiig pais ircl,
als rprss a ivsm i h halh car ssm a larg.
Frhrmr, i is a arg ivsm, i ha prvirs hmslvs
ar makig cisis ab hw sp h aiial rv whri will b ms sfl.
I wl b irsig rsa hw h aiial rv
gra b h vchr sbsi has iflc ak-hm pa fr
prvirs. th VMA migh csir a mhl r qarrl srv f
prvirs mir h cmic impac f h prgram bh
ak-hm pa a h spcific capial ivsms h chs mak.
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PRoGRAM CoStS
tabl 4 prss h prgram css fr h SM a FP vchrs fr
h pri Jl 2006ocbr 2008. th al prgram xpir,
iclig vrha css a rimbrsm prvirs, is giv iKa shilligs a i rs as rpr KfW a h f Phas I i
ocbr 2008. th pri f css sp maagm, raiig, a
markig is 21 prc f h prjc bg.
table 4: tOtal exPenDitures On Phase i OF the
Oba VOuCher PrOgram, June 2006OCtOber
2008
All amounts are as reported to KfW in 2008.
epd eo Ks
dirc srvic css
Rimbrsig GVR VSPs 8,908 914,184
Rimbrsig FP VSPs 201,810 19,817,182
Rimbrsig SM VSPs 4,621,540 463,195,705
Subtotal 4,832,258 483,927,071 79%
Maagm css
disribr raiig 8,109 804,410
Bak chargs / miscllas 10,277 1,034,950
GVR VSPs raiig 10,723 1,063,650
PwC pricig rpr i 2006 14,165 1,405,131
Prcss mirig (nCAPd) 18,554 1,840,541
Cmmissi isribrs 49,246 4,970,929
VSP accriai a raiig 63,785 6,223,222
Qali assrac (nHIF) 138,775 14,004,090
Markig a cmmicais 192,871 19,132,386
PwC maagm f 764,000 76,170,827
Subtotal 1,270,505 126,650,136 21%
tal xpir 6,102,763 610,577,207 100%
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th Ka vchr prgram was implm arss h brf rprciv a priaal mrbiiis i h cx f a rapil
grwig pplai wih a saga s f mr FP mhs. A h
sam im, h prgram was sig ircl sbsiiz ilizai
f rprciv halh srvics amg h pr, a accsm
h nCAPd maagm am a halh car prvirs a
rimbrsm ml f pam.
upak f h SM vchr srpass args a acc fr arl
half f all livris a crac faciliis. Hwvr, FP vchr pak
rmais lw; wih a risig tFR, his vchr shl b a high priri
gig frwar. th 2003 KdHS f ha 44 prc f marri
wm wa mr chilr, a ha h ms cmm rass
fr sig a mr FP mh hav wih far f harmfl si
ffcs a prsal r rligis ppsii. Wll-sig markig
ca imprv h prcpi f FP saf a mphasiz h avaags
f a smallr famil. Fcs grps ma b bficial i frhr xplrig
barrirs pak amg Ka wm. Giv ha FP was icl
i h rigial vchr prgram (iicaig ha icras FP pak
was a gvrm priri) a rcgizig h rmarkabl lw css
amiisr h FP vchr (1 prc amiisraiv css), chags
cl b ma imprv pak. Lw pak a sggss ha
markig ffrs hav b fll ffciv. Alraiv markig
summary
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sragis ma crag pak. oprais rsarch i FP pais
cisi-makig prcss cl als hlp iif pak barrirs b
markig csrais.
thr is a fr prvirs maiai saars f car a fr hprgram mir cmpliac. th x a qali f prgram
mirig is clar frm crr cmai, a i is likl ha
br mirig ffrs cl bfi h prgram. Srvic aa
ar cllc b PwC a shar wih nCAPd a KfW; hwvr,
aiial aa srvic qali a facili fiacs cl imprv h
mirig ffr.
I is impra ha hr b a rigrs amp sima h
pplai impac f h vchr prgram. t his, prgram fs
wl b s asi r xral rsrcs accss mak
cmpariss bw pplais srv a srv b vchrs.
Assssig pplai impac ma b pssibl lss h prgram
xpas a w srvic r a w ggraphic ara, wih a basli
hshl srv cllc aa pr-prgram halh cms i
aras wih a wih accss h vchr. Wih aa frm a fllw-
p srv afr 1218 mhs, cmpariss cl b ma avrag
halh sas f pplais xps h vchr srvic a
pplai xps.
th valai shl als csir h prgrams cs-ffcivss.
daa wl b raw frm cliics ha accp vchrs,b which ar hrwis similar cliics ha accp vchrs. Css
a pai cms cl b bsrv a cmpariss ma h
rlaiv cs-ffcivss f h vchr srvic. Mhl r qarrl
srvs f prvirs cl b s masr h ffc f h prgram
capial ivsms ma b prvirs, a cmpar rimbrsm
ams wih prvir css a fs fr -vchr pais.
th vchr prgram is bgiig a sc phas i which h crr
srvics will b xpa wihi h sam ggraphic aras. I his
xpa prgram, hr ar ppriis csir hw a larg
mbr f srvics, prhaps v a primar halh car packag, wl
pra ffcivl r a claims rimbrsm ml. up w,
h maagm agc has assm ha a f-fr-srvic ml is
h apprpria srag; hwvr, vic frm acrss h glb
iicas ha paig fs fr ach srvic is likl ic ilizai
b wha is cs ffciv c srvics amabl spplir
ic ma ar a h packag (Labll al. 1994).
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Spplir-ic ma ma parl xplai h icras i C-scis
as highr rimbrsm ras fr h prcr ma b icig mr
C-scis ha cssar r sirabl. I h crr rimbrsm
schl, rmal livris ar rimbrs a $72 a cmplica
livris ar rimbrs a $292. thr is vic ha C-scisicras sigifical afr faciliis wr crac, which ma hav
b h mch highr rimbrsms allw. Irsigl,
a cmparis f h prpri f C-scis amg vchr a
-vchr clis i h firs w ars f h prgram shws
ha h prpri is highr amg h -vchr clis. o
alraiv pricig ml is a cas-bas apprach i which a avrag
pric wl b pai fr all livris. Sch a apprach cl rmv
prvir icivs ha crag cssar bsric srgris.
ur h xpa prgram wih is
aiial srvics a mr cmplicamaagm, i ma mrg ha a cas-
bas rimbrsm srag, wih fwr
pric pis a grar iciv fr cs
caim, is mr ffici.
I h xpasi, w faciliis will likl
b a, iclig lwr-lvl gvrm
halh pss ha charg fr
rmal livris, lik highr-lvl halh
faciliis a hspials. th mivai
icl sch halh pss is frhr
habia h gvrm halh ssm
a rimbrsm prcss as a pam
ml fr pblic halh car. Hwvr,
h fr srvics rprs a pak
challg vchr srvics ha charg
a c-pam f KSh 200. th maagm
agc ma hrfr rcsir
vchr pricig pais. Whil prprl
For every woman who dies in childbirth, up
to 20 women suffer morbidities, often with
severe medical and social consequences.
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iciviz vchr isribrs ar h primar ga-kprs fr
vchr s, h pric f h vchr islf is a impra scar
mchaism fr argig a fra prvi. Ciig charg
fr h vchr ma rmi ilizai fr fr srvics, r riv
pais s rcivig rmal livr car fr f charg back ih has f rai birh aas. o h hr ha, isribig
h vchr fr f charg ma fail chck fra. Bh pial failrs
shl b csir wh sig h pric f h vchr.
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ACKnoWLedGMentS
this cas s scribs h challgs a cisis ma i sig
p a rig h KfW-f Ka op-Bas Apprach (oBA)
vchr prgram. th ahrs ar grafl saff a KfW, h Kanaial Criaig Agc fr Pplai a dvlpm, a
Miisr f Halh fr hir sppr a giac. th ahrs hak
h Pplai Ccil fr sharig prjc cms a h imags f
phgraphr Richar Lr.
th als hak Ra eichlr f Bra Brach Asscias fr hr rviw
f h cas s, a h uSAId-f Halh Ssms 20/20 Prjc,
l b Ab Asscias, which f h papr.
drs. davi Griffih a Clas Jaisch pla k rls i mivaig
irs i h vchr ml amg Ka cllags a sharig hKa vchr ml wih iraial parrs.
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27 P4P Case Studies - Kenya
ReFeRenCeSBllws, B., M. Hamil, a F. K. 2009. Vchrs fr Halh: Icrasig
ilizai f facili-bas FP a saf mhrh srvics i Ka.Bhsa, Md: Halh Ssms 20/20 prjc, Ab Asscias Ic.
Bllws, B., e. Mlg, a F. Baga. 2008. evalai f p-bas ai(oBA) i ugaa: Impac f crac faciliis a scial markvchrs kwlg, ilizai, a prvalc f sxall rasmiifcis (StIs) 2006-2007. Brkl, Califria: Vr Sragis frHalh a dvlpm.
Bllws, B., F. Baga, a e. Mlg. 2007. Prlimiar rpr: StI Prvalca Bhaviral Srv i Mbarara, Kirhra, Ibaa, Isigir a Bshidisrics - 2006. Brkl: Vr Sragis fr Halh a dvlpm.
Griffih, d. 2004. HIV/AIdS Prvi op-bas Ai: Ircig vchrssms fr halh car prvisi i ugaa (Prlimiar dsig). Frakfr:KfW (Grma dvlpm Bak).
Grsskrh, H., R. Gra, R. Has, d. Mab, a M. Wawr. 2000. Crlf sxall rasmi isass fr HIV-1 prvi: ursaig himplicais f h Mwaza a Rakai rials. Lac 355:1981-87.
Grsskrh, H., J. t, e. Mwijarbi, P. Maa, A. nicll, G. ka-Gia, J. nwll, H.Grsskrh, J. t, P. Maa, A. nicll, J. nwll, d. Mab, R. Has, F. Msha,K. Skr, J. Chagalcha, A. Klkk, e. Mwijarbi, G. ka-Gia, a K. Mg.1995. Impac f imprv ram f sxall rasmi isass HIV ifci i rral tazaia: ramis crll rial. th Lac346(8974):530-36.
Hagmr, e. 2005. Fial rpr prgram sig fr oBA i ugaa. Brli:IGeS.
H, M., e. ows, a P. M. Aki. 2009. ClaimMbil: egagig cflicig
sakhlr rqirms i halhcar i ugaa. Prs aIraial Cfrc Ifrmai a Cmmicai tchlgisa dvlpm, April 17-19, Cargi Mll uivrsi i Qaar; iICtd2009.
Kiwaka-Mkiibi, P. 2005. Ircig vchr ssms fr halhcar prvisi:Basli ai. Kampala: PS Cslig.
Kmh, G. B. 2003. Lw us f Rral Mari Srvics i ugaa:Impac f Wms Sas, traiial Blifs a Limi Rsrcs.Rprciv Halh Mars 11(21):16-26.
Maa, P. a d. Mab. 2004. Apprachs h crl f sxallrasmi ifcis i vlpig cris: l prblms a mr
challgs. Sx trasm Ifc 80(3):174-82.nwaha, F., e. Faxli, S. nma, a B. Hjr. 1999. La ppls prcpis f
sxall rasmi ifcis i ugaa. I J Std AIdS 10(11):709-17.
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Health Systems 20/20 is a ve-year (2006-201cooperative agreement No. HS-A-00-06-00010-funded by the U.S. Agency for InternationalDevelopment (USAID). The project addresses nancing, governance, operational, and capacitybuilding constraints that block access to and uspriority population, health, and nutrition servicby people in developing countries.Health Systems 20/20 offers global leadership,technical assistance, training, grants, research, ainformation dissemination.
Abt Associates Inc. (www.abtassociates.com) lea team of partners that includes:| Aga Khan Foundation | Bitrn y Asociados | brUniversity | Broad Branch Associates | diConsulting, LLP | Forum One CommunicationsInternational |Training Resources Group |TulanUniversity School of Public Health
DISCLAIMER: The authors views expressed her
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For more information about Health Systems 20/please contact:h s 20/20 | www.healthsystems2020Abt Associates Inc. | www.abtassociates.com4550 Montgomery Lane| Suite 800 North | Bethesda, MD 20814 | usaE-mail: [email protected]| www.healthsystems2020.org
rcodd Co: Bellows, Ben, MattHamilton, and Francis Kundu. September 2009.Vouchers for Health: Increasing Utilization of FaciliBased STI and Safe Motherhood Services in UgandMaternal and Child Health P4P Case Study.Bethesda, Maryland: Health Systems 20/20 projAbt Associates Inc.
Photos: Ben Bellows