In the world’s least developed countries, 120 of every 1,000 children die before turning five, a mortality rate 20 times that of high-income countries.1 Although the differences between high- and low-income countries are striking, this inequity in child mortality exists within countries as well. For example, across all regions of Indonesia, under-5 mortality is almost four times higher in the poorest fifth of the population compared to the wealthiest fifth.1 National health insurance schemes aim to reduce these disparities.
Yet despite the universal goals of national health insurance schemes, the poorest of the poor can be the last enrolled in such schemes, resulting in unequal access to health care services.2, 4, 5 Health voucher programs strive to improve equity by providing financial access to the most disenfranchised populations and filling the gaps in established social protection schemes. In this article, we examine how health voucher programs can address challenges in ensuring equity and discuss the strengths and weaknesses in a current voucher program in Kenya that is providing poor women with access to safe motherhood and family planning services.
Health Care Equity
The keystone of health care equity is equal access to care, meaning that health care provision shouldn’t depend on factors such as socioeconomic status, gender, or ethnicity. To meet that goal, programs that promote health care equity attempt to:
1. target marginalized populations,
2. treat patients with dignity and respect, and
3. deliver appropriate, high quality services.
In Kenya, the Ministry of Public Health and Sanitation (MoPHS) and the Ministry of Medical Services (MoMS; formerly the Ministry of Health) manage publicly funded health care, allocating almost $350 million USD for inputs per year.3 Traditional global budgeting approaches fund health care systems with direct payments for inputs, like physical infrastructure, human resources, and pharmaceuticals. Results-based approaches, on the other hand, pay providers for services provided.
Financing schemes like social health insurance can address issues with proper treatment and service quality, but some gaps persist. For example, social health insurance schemes cannot guarantee easy access for those who do not have transportation, lack knowledge of how to utilize available services, or face cultural barriers to accessing care. The result is that the poorest are often the last to benefit from social health insurance.4, 5 Vouchers are priced for and marketed to poor people in urban slums and rural areas. Thus vouchers can successfully reach the neediest patients who might otherwise slip through the cracks of the broader insurance scheme.
Increasing Equity for Kenyan Women
In 2006 the Kenyan government began the Reproductive Health Vouchers program with the ultimate goal of reducing maternal and infant mortality by improving access to health services for the poor. Women qualify for vouchers based on a poverty-grading tool. Eligible women can then purchase vouchers for services such as maternity care, family planning, and gender-based violence counseling (no fee). Vouchers cost 100-200 Kenyan shillings (approximately $1-2 USD). Facilities submit claims and are reimbursed per service.
The Population Council baseline evaluation7 found that between 2006 and 2010, vouchers appeared to increase socio-economic equity between poor and non-poor women in family planning and maternity care service delivery, compared to similar populations without the voucher service. In addition, some service providers stated that the program significantly led to improvements in both service quality and physical infrastructure. A service provider in Kitui reported, “Because of that reimbursement, we are doing very well… we were able to build that... that building there.... We have constructed a maternity... and have done a lot of renovations… so to us it’s a benefit.”
Voucher patients were satisfied with services provided as well, especially in public health facilities: 92% of voucher clients reported being satisfied with the services they received compared to 85% of non-voucher clients at non-contracted facilities.7
Service utilization, which is instrumental to improving health outcomes, also increased with vouchers. Significantly more voucher clients than non-voucher clients used reproductive health services such as long-term family planning methods, skilled delivery and post-natal care services.7
A voucher client in Kitui provided a clear explanation of how vouchers increase equity: “There are changes because most of us never used to go to clinic. We would get pregnant and stay at home. When you’re told to go to hospital you would say, I don’t have money, I don’t have money. But now you won’t find anyone staying at home.”
REFERENCES
1. CG Victora, A Wagstaff, JA Schellenberg, D Gwatkin, M Claeson, and JP Habicht, Applying an equity lens to child health and mortality: more of the same is not enough. Lancet, 362 (2003), pp. 233-241.
2. DR Gwatikin and A Ergo, Comment: Universal health coverage: friend or foe of health equity? Lancet, 377 (2011), pp. 2160 -2161
3. Kenya Ministry of State for Planning, National Development and Vision 2030: Public Expenditure Review. (2010), pp. 75-99.
4. T Ensor and S Cooper, Overcoming Barriers to Health Service Access and Influencing the Demand Side through Purchasing. Health, Nutrition and Population Discussion Paper (2004), The World Bank.
5. A Acharya, S Vellakkal, S Kalita, et al. Do social health insurance schemes in developing country settings improve health outcomes and reduce the impoverishing effect of healthcare payments for the poorest people? Systematic review (2010), DfID.
6. J Larsen and A Van Middelkoop, The “unbooked” mother at King Edward VIII Hospital, Durban. South African Med J, 62 (1982), pp. 483–486.
7. The Reproductive Health Vouchers Program in Kenya: Summary of Findings from Program Evaluation. Reproductive Health Vouchers Evaluation Team (2011), Nairobi: Population Council, September 20, 2011.
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