Research on demand-side health care financing approaches such as output-based aid (OBA) programs have focused on evaluating the role of the programs in increasing utilization of services, quality of services among others, with limited focus on the experiences and perceptions of the target communities. This paper examines community views of an output-based aid voucher program in Kenya.
A household survey was conducted in 2010 among 1,336 women aged 15-49 years living in the catchment areas of health care providers in three districts participating in the voucher program. Twenty seven focus group discussions were conducted with voucher users, non-users, opinion leaders and voucher distributors in the three sites, including Nairobi that are participating in the program. Analysis of the quantitative data used frequency distributions. Qualitative data were transcribed and analyzed by adopting framework analysis and further triangulation of themes across respondents.
The vast majority (84%) of survey respondents had heard about the safe motherhood voucher, compared to 24% and 1% that had heard about the family planning and GBVRS vouchers respectively. Similarly, 20% of the respondents had used the safe motherhood voucher compared to 2% and 0% for family planning and GBVRS vouchers respectively. From the communities’ perspective, the voucher program is associated with improvements in access to health services for poor women, perceived improved quality of care, and empowerment of women to make health care decisions. However, communities also cited difficulties in accessing some accredited health facilities, limitations with the system for selling vouchers, lack of male involvement in women’s reproductive health issues, and poor understanding of the benefits available through purchasing a subsidized voucher.
Our study showed that output based aid project is viewed by the community as a feasible system for increasing service utilization, quality and reducing financial barriers to accessing reproductive health services. Nonetheless, there are variations to reported success for the various vouchers. Further, our findings suggest that the use of vouchers alone cannot adequately address access related barriers to utilization of reproductive healthcare services; techniques of program execution and policies also influence access and level of choice.