Journal Article

Population-level impact of vouchers on access to health facility delivery for women in Kenya: A quasi-experimental study

Background
Available evidence indicates that vouchers improve service utilisation among the target populations. A key question is whether increased utilisation results from improved access or from shifting clients from nonaccredited to contracted service providers. This paper examines whether the safe motherhood voucher programme in Kenya is associated with improved access to health facility delivery over time using information on births within 2 years preceding baseline and follow-up surveys in voucher and comparison sites.

Methods
Data were collected in 2010–11, and in 2012, among 2933 and 3094 women aged 15–49 years reporting 962 and 1494 births within 2 years before the respective surveys. Respondents were sampled from among those living within a 5 km radius of three groups of facilities: those nearby health facilities that had been in the voucher programme since 2006; those nearby facilities that were added to the programme in 2010–11; and those nearby similar facilities in comparison sites. Analysis entails cross-tabulations and estimation of multilevel random-intercept logit models.

Findings
The proportion of births occurring at home declined by more than 10 percentage points, while the proportion of births delivered in health facilities increased by a similar margin over time in voucher sites. The increase in facility-based births was consistent across public and private health facilities. There was also a significant increase in the likelihood of facility-based delivery (odds ratio 2·04; 95% CI 1·40–2·98 in the 2006 voucher arm; 1·72; 1·22–2·43 in the 2010–11 voucher arm), which was accompanied by significant decline in home-based births in voucher sites over time. By contrast, there were no significant changes in the likelihood of facility or home-based delivery in the comparison sites over time.

Interpretation
The voucher programme contributed to improved access to institutional delivery by shifting births from home to health facilities over time.