In response to unacceptably high rates of maternal mortality in Kenya, the German development bank KfW designed an innovative voucher scheme to provide access for poor women to good quality maternal health care, family planning, and treatment for gender-based violence. This project, now paid for in part by the Kenyan government, is a performance-based program that empowers women to seek this essential health care. With innovative management and fraud prevention processes, the program also lays the groundwork for a more comprehensive health insurance system.
Recently, the German Health Practice Collection published a report on this program to share good practices and lessons learnt. We asked Sue Armstrong, the report’s author, to share her impressions of the program from her visits to Kenya.
Rose Reis: What drove you to write about this program?
Sue Armstrong: I’ve been interested in maternal health since working with WHO on the launch of the Safe Motherhood Initiative in 1987, following which I edited and contributed to a book on the topic for WHO, “Preventing Maternal Deaths”, in conjunction with Erica Royston.
Unfortunately, little has changed: of the eight Millennium Development Goals, least progress has been made towards meeting the target on MDG 5, which is to reduce maternal mortality by three quarters between 1990 and 2015.
Kenya’s maternal mortality rate has actually increased since 1990. Because pregnancy and childbirth are natural processes, they are all too often neglected by national health services which, in much of the developing world, still tend to be disease-orientated.
Few people realize that pregnancy complications are actually very common. According to UNFPA, up to 40% of pregnant women may develop complications, often without warning, before, during or just after childbirth, and for around 15% of all pregnant women the complications may be life-threatening: the survival of mother and child depends on access to quality maternity services that can manage such cases.
Kenya’s voucher program empowers women to choose from a list of accredited facilities, public or private, to deliver their babies. Women no longer have to live with the fear of complications that could financially ruin their families.
RR: Do women understand the value of a safe delivery voucher?
SA: There is high demand for the vouchers. Distributors discuss reproductive health issues and introduce the concept of vouchers at community meetings—in schools, churches, women’s groups, and public gatherings. Talking to a group of women attending an antenatal clinic, I found that almost every one knew of someone who had died in childbirth.
To determine a woman’s poverty level and eligibility for vouchers, field managers visit her at home to assess its condition. They go through a check list with questions as: Does she have access to water and sanitation? Does she live in a shantytown, or a nicer area? Is there an income? How many people share the home?
At right: Voucher distributor Violet Auma explains how the safe motherhood voucher works to a new client in Miwani, near Kisumu.
Unfortunately the demand for services is far greater than the program can meet. Voucher distributors told me that women from outside the catchment area sometimes try to participate. A fairly common strategy is to ‘borrow’ a friend’s house within the catchment area for the distributor’s visit. If the voucher distributors suspect this might be the case, they will ask leading questions such as what color a woman’s toothbrush is. But recognizing that most of these cases are motivated by very real need, the voucher distributors are trained to handle them with kindness and diplomacy rather than confrontation.
RR: What were some of the benefits of offering women a choice between public and private facilities?
SA: The involvement of health care providers from all sectors—public, for-profit, NGO, faith-based organizations—had many benefits. Private health facilities often operate in places where there are no public services, so the involvement of all sectors helps achieve maximum coverage of the target population.
Competition between health facilities encourages investment in services and tends to drive up quality, so the greater the competition the better. Private facilities benefit from inclusion in the voucher program in that it expands their market, bringing them clients who could not otherwise afford their fees and allowing them to operate at greater capacity.
RR: Can you give examples of ways facilities used the revenue from the program?
SA: Facilities would use revenue from vouchers to ensure all customers had better treatment and a better experience. At one health center we visited, managers had invested in amenities to improve customer satisfaction and quality, such as curtains to give women privacy around the beds, an improved hot water system, and incinerators for waste disposal outside. One hospital had put the money earned from the scheme towards a new maternity wing. Another clinic had installed tea making facilities, which had a huge impact on staff morale. They were working hours without a rest and now they could take a tea break.
Women in hospital.
RR: Could a voucher scheme work without other investments in facilities?
SA: A voucher scheme can only be established where there is an existing health infrastructure; therefore ‘supply side’ investment in health services, including capacity-building and strengthening of existing facilities, are essential complements to output-based aid.
RR: What is the future of the scheme?
SA: There are plans to extend the voucher scheme to further sites. However, this is part of a wider vision for Kenya’s health services based on a national social health insurance scheme. The voucher program incorporates many of the key features of a health insurance scheme, such as systems for accreditation and quality assurance of facilities, and for registering clients, processing claims and combating fraud. For this reason it is being closely watched as a stepping stone towards a nationwide health insurance scheme.
Read Sue Armstrong’s report, Vouchers: making motherhood safer for Kenya’s poorest women: A publication in the German Health Practice Collection. Read a blog interview with a researcher studying this program here.