Kenya
Quick Facts Summary Table
| Program title | Reproductive Health Output-Based Aid (OBA) Voucher Program |
| Location | Kisumu, Kiambu, and Kitui districts. Korogocho and Viwandani slums (Nairobi) |
| Period | 2005-2012; Constituting Phase I (October 2005-October 2008) and Phase II (June 2009 –2012) |
| Background | This voucher scheme co-funded by the German Development Bank (KfW) and the Kenyan government (US$ 9.55 million for Phase I) offers safe motherhood package of antenatal services and attended delivery by qualified health workers, long-term family planning methods and gender-based violence recovery services at accredited facilities. The safe motherhood voucher cost to clients is Ksh 200 ($2.70) and the Family Planning voucher is Ksh 100 ($1.35), while the service providers are reimbursed up to a maximum of Ksh 20,000 for complicated deliveries. |
| Partners | Donor: German Development Bank (KfW), Government: Ministry of Public Health and Sanitation/Ministry of Medical Services, Project Management Unit: The National Co-ordinating Agency for Population and Development (NCAPD), Monitoring and Evaluation: Population Council, Voucher Management Agency: PriceWaterhouseCoopers (PWC), Technical Advisor: IGES GmBH (Phase I), EPOS Health Management (Phase II). |
| Numbers served | Between June 2006 and February 2010, 82,523 Safe Motherhood claims,12,643 family planning claims and 480 gender violence recovery claims were submitted. 93% were reimbursed. |
| Service provider reimbursement rates Exchange rate 75 Ksh=US$1 |
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| VMA role | Claims processing, fraud monitory, monitor service quality, monitor and evaluate program objectives |
| Provider accreditation | Service providers in the project districts mapped and shortlisted on their capacity to deliver accredited voucher services. |
| Poverty grading | To ensure accurate targeting of the poorest and economically most vulnerable voucher recipients, a participatory poverty grading tool was used in the project districts developed with indicators specific to each district. Markers for poverty included housing, medical access, water source, rent, sanitation, income and number of meals taken per day. |
| Marketing/Health education | Advertising agency was used to implement a one-month launch campaign to increase awareness about Family planning and Safe Motherhood vouchers. Channels included radio spots, road shows, community events, door-to-door communication and use of IEC promotional materials. |
| Evaluation findings | Uptake for Safe Motherhood package services was higher at 77% redeemed vouchers compared to Family Planning services which redeemed 41% of the total distributed vouchers indicating popularity of the voucher program in eliminating economic barriers for poor pregnant women who previously did not deliver at facilities. Anecdotal evidence has for instance shown that women in Kitui purchased the vouchers as insurance against delivery complications rather than with obvious intentions to use for normal deliveries. At facility level, there has been an increase in deliveries even among non-voucher clients. |
| Evaluation gaps | Impact on health status and utilization at population level remains unknown, a factor which will be addressed by the Population Council’s evaluation of the RH-OBA Voucher Program. |
| Current status | Phase I of pilot completed. A design mission is underway for Phase II. Experiences and lessons learnt in Phase I will be incorporated in the redesign and strengthening of Phase II including a shift of overall project management from NCAPD to the Ministry of Public Health and Sanitation. |
| Innovations | Unlike other voucher programs, both private and public sector facilities were contracted in Kenya allowing for greater competition and better service coverage. This ensures that government only reimburses the public facilities for specific service based on their service costs rather than on an input-basis. |
Additional Information
National reproductive and maternal health indicators in Kenya are poor. In 2007, there were an estimated 415 maternal deaths per 100,000 live births, 77 infant deaths (under 1 year old) per 1,000 live births, and 115 deaths of children under 5 years old per 1,000 live births.
In 2006, with financial support from the German Development Bank (KfW) the Government of Kenya embarked on a performance-based reproductive health program that incentivized access to women’s healthcare. Unattended delivery is the greatest risk factor for maternal mortality and morbidity and in Kenya only 42 percent of all births are assisted by a health professional. An effective means to improve that figure is an incentivized Safe Motherhood package of antenatal services and attended delivery by a qualified health worker. The Kenya National Coordinating Agency for Population and Development (NCAPD) is implementing an output-based aid (OBA) program in the rural districts of Kisumu, Kitui, and Kiambu as well as the Nairobi informal settlements of Viwandani and Korogocho, representing a population of approximately three million.
NCAPD manages three service packages: the safe delivery program, a long-term family planning methods voucher, and a gender-based violence recovery service. PriceWaterhouseCoopers runs the claims processing center and the contracted facilities were accredited by the National Hospital Insurance Fund (NHIF).
Public Sector (UNICEF) Maternal Health Voucher
Since 2005 UNICEF has been working with the Kenya Ministries of Health (MoH) on a US$2.5 million output-based incentives system for births at MoH facilities in the arid, underserved northeast region. Government facilities receive 500 shillings (~US$6.60) for each delivery. Lower level facilities (dispensaries) were also reimbursed for transport costs if the laboring mother needed to be referred to a higher level facility for obstetric surgery. Vouchers were originally handed out as a reminder that the delivery was free to women who made at least one antenatal care (ANC) visit. However, expectant mothers did not need to bring the voucher to the facility and currently vouchers are not routinely distributed.
There are about 60 facilities participating in the program. Reimbursement claims are made quarterly after a MoH team of provincial and district level officers inspect the facility for basic hygiene, functional equipment, and supplies and compare the birth registry against the BCG immunization records. There should be a near match between live births and the numbers of BCG immunizations. If the facility passes inspection, it is paid 500 shillings for each birth in the past 3 months. The payment is intended to incentivize a clean delivery location and discourage misuse of scarce medical supplies. The reimbursement does not cover the delivery cost as the government already is paying salaries, supplies, and other health post expenses. The transportation reimbursement, on the other hand, does reimburse for fuel.
A UNICEF Executive Board mission to Kenya in March observed that the “incentive has raised the percentage of women seeking skilled deliveries in the province from 8 per cent to 25 per cent” (see bottom of this UNICEF link).
Additional links
Public-private RH-OBA project website
KfW story “Kenya – Vouchers for Health”
Lenel and Griffith, 2007, “Voucher schemes in the health sector” [PDF]. Working paper.
Constituting Phase I (October 2005-October 2008) and Phase II (June 2009 –2011) with a bridging period between November 2008 to June 2009.
