Population Council Research that makes a difference

2011 International Conference on Family Planning
29 November–2 December 2011

Abstract

"The impact of the reproductive health vouchers program in Kenya on the use of long-term family planning methods"
Francis Obare, Charlotte Warren, Rebecca Njuki, Timothy Abuya, Joseph Sunday, Ian Askew, and Benjamin Bellows

Background
The Government of Kenya has implemented the reproductive health vouchers program since 2006 with funding from the German Development Bank. Its objective is to significantly reduce maternal and neonatal mortality by improving access to appropriate reproductive health services for the poor through incentives for increased demand and improved service provision. The vouchers are made available through distributors appointed by the voucher management agency (VMA) to poor women in Kisumu, Kitui, and Kiambu districts, and in Korogocho and Viwandani informal settlements in Nairobi for comprehensive safe motherhood services and long-acting or permanent family planning methods (LAPM) at a subsidized cost (equivalent US $2.50 for safe motherhood and US $1.25 for LAPM vouchers). The distributors use a poverty grading tool consisting of eight items on household assets and amenities that are unique to each district to identify poor women who qualify for the vouchers (those scoring 8–16 points). Additional vouchers are made freely available for women seeking gender-based violence recovery services. The LAPM subsidized by the program include implants, intrauterine contraceptive device (IUCD), and voluntary surgical contraception. Estimates from the Kenya Demographic and Health Surveys show that the use of these methods remains low mostly due to client-provider misconceptions, service delivery constraints, and poor quality of care.

Main question/hypothesis
This paper examines whether the voucher program is associated with increased utilization of LAPMs. It compares the use of LAPM subsidized by the program among women from communities that have been exposed to the voucher program since 2006 and those that have not had such exposure. The key assumption is that the program had both direct (individuals from communities exposed to it bought and used a voucher to obtain services) and indirect (they influenced their neighbors who never bought or used vouchers through their experiences) effects on utilization of LAPM. It further compares the use of the methods among voucher and non-voucher clients at the facility level.

Methodology
The data are from a quasi-experimental study implemented by the Population Council between February and November 2010 to evaluate the impact of the voucher program on reproductive health behaviors and status in Kenya. Household-level data were collected from 2,527 women of reproductive age (15–49 years) living within five kilometer-radius of facilities contracted to provide services to voucher clients in three voucher sites (Kisumu, Kiambu and Kitui) and similar non-contracted facilities in three non-voucher sites (Makueni, Nyandarua and Uasin Gishu districts). Of the women interviewed, 11% had ever used the vouchers. Client exit interviews were also conducted with 1,823 women seeking family planning, antenatal and postnatal care services from 55 health facilities (35 in voucher and 20 in non-voucher sites) with voucher clients comprising 29% of the sample. A total of 313 women interviewed upon exit sought family planning services with 15% of them being voucher clients. Analysis entails cross-tabulations with Chi-square tests as well as estimation of multilevel logit models. The results are presented in terms of percentages and odds ratios (OR).

Results
At the household level, 9% of the women had ever used LAPM (implants, IUCD or bilateral tubal ligation) while 7% used the methods in the past 12 months before the survey. The proportion of women that had ever used LAPM was slightly higher among those from communities exposed to the voucher program since 2006 than among those from the comparison sites (12% versus 10%). A similar pattern is noted for use of LAPM in the past 12 months preceding the survey (8% versus 7%). Results from the multilevel logit analysis show that women from communities exposed to the program since 2006 were significantly more likely to have ever used LAPM compared to their counterparts from comparison sites (OR: 1.5; 95% confidence interval [CI]: 1.0–2.1). Although they also had a higher likelihood of having used LAPM in the past 12 months before the survey compared to those from comparison sites, the difference was not statistically significant (OR: 1.4; 95% CI: 0.9–2.2). At the facility level, 12% of the women seeking family planning services had previously used LAPM while 14% obtained the methods during the visit. The proportion of voucher clients that obtained LAPM during the visit was significantly higher than that of non-voucher clients (54% versus 7%; p<0.01). Among voucher clients, the proportion that obtained LAPM during the visit was nearly double the proportion that had previously used the methods (54% versus 29%; p<0.01).

Knowledge contribution
The reproductive health vouchers program in Kenya is associated with increased utilization of LAPM among voucher clients and among women from communities that have been exposed to it although overall uptake of the methods still remains low.

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Diane Rubino: drubino@popcouncil.org; +1 212 339 0617