Vouchers for health: A demand side output-based aid approach to reproductive health services in Kenya

Abstract

Reaching the United Nation's Millennium Development Goals has been a focus for many countries and development partners. In Kenya, as in many other countries with low levels of development, access to and equity of basic quality health services is limited, especially for the very poor. Among poor populations, maternal mortality is high as access to medical care and financial means are lacking. In 2005, the Governments of Kenya and Germany in cooperation with KfW Banking Group made funds available for the Reproductive Health OBA Voucher Programme offering vouchers for Safe Motherhood, Family Planning and Gender Violence Recovery Services. This programme, herein referred to as Vouchers for Health, was launched in June of 2006 in five Kenyan districts with the aim of providing health services for safe deliveries, long-term family planning methods and victims of gender violence. The way that the programme is being implemented in Kenya demonstrates that the voucher-based approach comprises a variety of key structural elements of a national health insurance scheme: accreditation; quality assurance; reimbursement system; claims processing; integrating the private sector; client choice; provider competition; and access to and equity of services provided.

Keywords:

• output-based aid
• consumer-led demand-side financing
• reproductive and child health
• public–private partnerships
• vouchers for health

Notes

1. In the industrial world, such accounts on quality may be more objective owing to data recording and availability (recurring hospital reports and internet portals which analyse performance indicators). In developing countries, where access to objective data and information on quality is limited, these accounts on perceived quality are the most feasible approach to consumer choice and demand.

2. Low-income earners lose work productivity during the time spent to travel to and stay at the health care provider; the costs of travelling (time and/money) and additional costs of treatment as well as bribery and co-payment make seeking health care a ‘bad’ (Arhin-Tenkorang 2001).

3. GVRS voucher was altered during the run of the programme into a service which can be attained at accredited facilities but is not sold in voucher form. This is due to the fact that gender violence (similar to an accident) is an unpredictable event for which no voucher is bought in advance. Up until October 2007 a total of 246 GVR services were claimed and reimbursed by the VMA to the accredited facilities.

4. The VMA assignment was tendered. PriceWaterhouseCoopers in Kenya won the bid.

5. Quality Assurance in Reproductive Health: handbook for the OBA Programme Kenya, eds. C. Warren, C. Rakuom, and A. Mwangi, working draft, July 2006.

6. For instance, those VSP are able to perform a normal delivery, but do not meet technical or staff criteria to perform caesarean sections.

7. The review is based on a ‘relevant costs approach’, excluding costs that would still incur unto the service providers regardless of their participation in the OBA programme, such as general overheads or establishment costs (rent, security, etc.). A review is also necessary to ensure that genuine costs for providing the services are recovered without any cross-subsidisation by the service providers, both in the private sector and the public sector.

8. In the different districts reimbursements rates vary. In Kisumu District, for example, FP services are reimbursed with a base rate of 1000 KES (including IUCD insertion), a 2000 KES flat rate for hormonal implants, and 3000 KES flat rate for sterilisation. For SMH services, a 4000 KES flat rate was set for a normal delivery and a flat rate of 20,000 KES set for a caesarean section, additional costs that may occur due to complications are reimbursed on a cost-per-case basis. This needs to be documented adequately.

9. WHO Fortelesa Declaration of 1985.

10. Ronsmans et al. (2006) show that the accessibility of the especially poor to life saving caesarean sections is very limited.

11. Compare to Mati et al. (2008).

12. Marie Stopes International is a provider of sexual and reproductive health care services. Marie Stopes International: support to Kenya's output-based programme – adaptation of the participatory poverty grading tool.

13. Only very few incidents of down-coding have been recorded until now.

14. Provider workshop held in June 2008 in Kenya.