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Benjamin Bellows - One of the best experts on this subject based on the ideXlab platform.
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initiation and continuity of maternal healthcare examining the role of Vouchers and user fee removal on maternal health service use in kenya
Health Policy and Planning, 2019Co-Authors: Mardieh Dennis, Lenka Benova, Timothy Abuya, Matteo Quartagno, Benjamin Bellows, Oona M R CampbellAbstract:This study explores the relationship between two health financing initiatives on women's progression through the maternal health continuum in Kenya: a subsidized reproductive health Voucher Programme (2006-16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the Voucher Programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the Voucher Programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P < 0.001) were also positively associated with use of continuous care among ANC users. Among continuous care users, early ANC was associated with increased odds of completing the maternal health pathway as recommended (aOR: 3.80, P < 0.001). Higher parity was negatively associated with all three outcomes, while having health insurance was positively associated with each outcome. The impact of other sociodemographic factors such as maternal age, education, wealth quintile, urban residence, and employment varied by outcome; however, the findings generally suggest that marginalized women faced greater barriers to early ANC initiation and continuity of care. Health financing and women's timing and source of ANC are strongly related to their subsequent progression through the maternal health pathway. To increase continuity of care and improve maternal health outcomes, policymakers must therefore focus on equitably reducing financial and other barriers to care seeking and improving quality of care throughout the continuum.
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Initiation and continuity of maternal healthcare: examining the role of Vouchers and user-fee removal on maternal health service use in Kenya.
Health policy and planning, 2019Co-Authors: Mardieh Dennis, Lenka Benova, Timothy Abuya, Matteo Quartagno, Benjamin Bellows, Oona M R CampbellAbstract:This study explores the relationship between two health financing initiatives on women's progression through the maternal health continuum in Kenya: a subsidized reproductive health Voucher Programme (2006-16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the Voucher Programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the Voucher Programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P
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evaluating the impact of a maternal health Voucher Programme on service use before and after the introduction of free maternity services in kenya a quasi experimental study
BMJ Global Health, 2018Co-Authors: Mardieh Dennis, Oona M R Campbell, Lenka Benova, Timothy Abuya, Matteo Quartagno, Angela Baschieri, Benjamin BellowsAbstract:Introduction From 2006 to 2016, the Government of Kenya implemented a reproductive health Voucher Programme in select counties, providing poor women subsidised access to public and private sector care. In June 2013, the government introduced a policy calling for free maternity services to be provided in all public facilities. The concurrent implementation of these interventions presents an opportunity to provide new insights into how users adapt to a changing health financing and service provision landscape. Methods We used data from three cross-sectional surveys to assess changes over time in use of 4+ antenatal care visits, facility delivery, postnatal care and maternal healthcare across the continuum among a sample of predominantly poor women in six counties. We conducted a difference-in-differences analysis to estimate the impact of the Voucher Programme on these outcomes, and whether Programme impact changed after free maternity services were introduced. Results Between the preintervention/roll-out phase and full implementation, the Voucher Programme was associated with a 5.5% greater absolute increase in use of facility delivery and substantial increases in use of the private sector for all services. After free maternity services were introduced, the Voucher Programme was associated with a 5.7% higher absolute increase in use of the recommended package of maternal health services; however, disparities in access to facility births between Voucher and comparison counties declined. Increased use of private sector services by women in Voucher counties accounts for their greater access to care across the continuum. Conclusions Our findings show that the Voucher Programme is associated with a modest increase in women’s use of the full continuum of maternal health services at the recommended timings after free maternity services were introduced. The greater use of private sector services in Voucher counties also suggests that there is need to expand women’s access to acceptable and affordable providers.
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Estimating willingness to pay for maternal health services: the Kenya reproductive health Voucher Programme
2015Co-Authors: Lucy Kanya, Benjamin Bellows, Francis Obare, Brian Mdawida, Charlotte E. Warren, Ian AskewAbstract:The reproductive health Voucher Programme is implemented by the Government of Kenya with major funding from the German Development Bank (KfW). The evaluation project was funded by the Bill & Melinda Gates Foundation and implemented by the Population Council in collaboration with the National Council for Population and Development (NCPD), the Ministry of Health and PriceWaterhouseCoopers.
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A Taxonomy and Results from a Comprehensive Review of 28 Maternal Health Voucher Programmes
Journal of Health Population and Nutrition, 2013Co-Authors: Benjamin Bellows, Claudia Morrissey Conlon, Elizabeth S. Higgs, John Townsend, Matta G. Nahed, Karen Cavanaugh, Corinne G. Grainger, Jerry Okal, Anna C. GorterAbstract:It is increasingly clear that Millennium Development Goal 4 and 5 will not be achieved in many low- and middle-income countries with the weakest gains among the poor. Recognizing that there are large inequalities in reproductive health outcomes, the post-2015 agenda on universal health coverage will likely generate strategies that target resources where maternal and newborn deaths are the highest. In 2012, the United States Agency for International Development convened an Evidence Summit to review the knowledge and gaps on the utilization of financial incentives to enhance the quality and uptake of maternal healthcare. The goal was to provide donors and governments of the low- and middle-income countries with evidence-informed recommendations on practice, policy, and strategies regarding the use of financial incentives, including Vouchers, to enhance the demand and supply of maternal health services. The findings in this paper are intended to guide governments interested in maternal health Voucher Programmes with recommendations for sustainable implementation and impact. The Evidence Summit undertook a systematic review of five financing strategies. This paper presents the methods and findings for Vouchers, building on a taxonomy to catalogue knowledge about Voucher Programme design and functionality. More than 120 characteristics under five major categories were identified: Programme principles (objectives and financing); governance and management; benefits package and beneficiary targeting; providers (contracting and service pricing); and implementation arrangements (marketing, claims processing, and monitoring and evaluation). Among the 28 identified maternal health Voucher Programmes, common characteristics included: a stated objective to increase the use of services among the means-tested poor; contracted-out Programme management; contracting either exclusively private facilities or a mix of public and private providers; prioritizing community-based distribution of Vouchers; and tracking individual claims for performance purposes. Maternal Voucher Programmes differed on whether contracted providers were given training on clinical or administrative issues; whether some form of service verification was undertaken at facility or community-level; and the relative size of Programme management costs in the overall Programme budget. Evidence suggests Voucher Programmes can serve populations with national-level impact. Reaching scale depends on whether the Voucher Programme can: (i) keep management costs low, (ii) induce a large demand-side response among the bottom two quintiles, and (iii) achieve a quality of care that translates a greater number of facility-based deliveries into a reduction in maternal morbidity and mortality.
Charlotte E. Warren - One of the best experts on this subject based on the ideXlab platform.
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Estimating willingness to pay for maternal health services: the Kenya reproductive health Voucher Programme
2015Co-Authors: Lucy Kanya, Benjamin Bellows, Francis Obare, Brian Mdawida, Charlotte E. Warren, Ian AskewAbstract:The reproductive health Voucher Programme is implemented by the Government of Kenya with major funding from the German Development Bank (KfW). The evaluation project was funded by the Bill & Melinda Gates Foundation and implemented by the Population Council in collaboration with the National Council for Population and Development (NCPD), the Ministry of Health and PriceWaterhouseCoopers.
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Safe motherhood Voucher Programme coverage of health facility deliveries among poor women in South-western Uganda
Health Policy and Planning, 2013Co-Authors: Lucy Kanya, Timothy Abuya, Francis Obare, Charlotte E. Warren, Ian Askew, Benjamin BellowsAbstract:There has been increased interest in and experimentation with demand-side mechanisms such as the use of Vouchers that place purchasing power in the hands of targeted consumers to improve the uptake of healthcare services in low-income settings. A key measure of the success of such interventions is the extent to which the Programmes have succeeded in reaching the target populations. This article estimates the coverage of facility deliveries by a maternal health Voucher Programme in South-western Uganda and examines whether such coverage is correlated with district-level characteristics such as poverty density and the number of contracted facilities. Analysis entails estimating the Voucher coverage of health facility deliveries among the general population and poor population (PP) using Programme data for 2010, which was the most complete calendar year of implementation of the Uganda safe motherhood (SM) Voucher Programme. The results show that: (1) the Programme paid for 38% of estimated deliveries among the PP in the targeted districts, (2) there was a significant negative correlation between the poverty density in a district and proportions of births to poor women that were covered by the Programme and (3) improving coverage of health facility deliveries for poor women is dependent upon increasing the sales and redemption rates. The findings suggest that to the extent that the Programme stimulated demand for SM services by new users, it has the potential of increasing facility-based births among poor women in the region. In addition, the significant negative correlation between the poverty density and the proportions of facility-based births to poor women that are covered by the Voucher Programme suggests that there is need to increase both Voucher sales and the rate of redemption to improve coverage in districts with high levels of poverty.
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Population-level impact of Vouchers on access to health facility delivery for women in Kenya: a quasi-experimental study
The Lancet, 2013Co-Authors: Francis Obare, Timothy Abuya, Charlotte E. Warren, Ian Askew, Benjamin BellowsAbstract:Abstract 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 non-accredited 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. Funding The reproductive health Vouchers Programme is implemented by the Government of Kenya with major funding from the German Development Bank. The evaluation project was funded by the Bill & Melinda Gates Foundation.
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Community-level impact of the reproductive health Vouchers Programme on service utilization in Kenya.
Health policy and planning, 2012Co-Authors: Francis Obare, Timothy Abuya, Charlotte E. Warren, Ian Askew, Rebecca Njuki, Joseph Sunday, Benjamin BellowsAbstract:This paper examines community-level association between exposure to the reproductive health Vouchers Programme in Kenya and utilization of services. The data are from a household survey conducted among 2527 women (15–49 years) from Voucher and comparable non-Voucher sites. Analysis entails cross-tabulations with Chi-square tests and significant tests of proportions as well as estimation of multi-level logit models to predict service utilization by exposure to the Programme. The results show that for births occurring after the Voucher Programme began, women from communities that had been exposed to the Programme since 2006 were significantly more likely to have delivered at a health facility and to have received skilled care during delivery compared with those from communities that had not been exposed to the Programme at all. There were, however, no significant differences in the timing of first trimester utilization of antenatal care (ANC) and making four or more ANC visits by exposure to the Programme. In addition, poor women were significantly less likely to have used safe motherhood services (health facility delivery, skilled delivery care and postnatal care) compared with their non-poor counterparts regardless of exposure to the Programme. Nonetheless, a significantly higher proportion of poor women from communities that had been exposed to the Programme since 2006 used the services compared with their poor counterparts from communities that had not been exposed to the Programme at all. The findings suggest that the Programme is associated with increased health facility deliveries and skilled delivery care especially among poor women. However, it has had limited community-level impact on the first trimester timing of antenatal care use and making four or more visits, which remain a challenge despite the high proportion of women in the country that make at least one antenatal care visit during pregnancy.
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Increase in facility-based deliveries associated with a maternal health Voucher Programme in informal settlements in Nairobi, Kenya
Health policy and planning, 2012Co-Authors: Benjamin Bellows, Charlotte E. Warren, Catherine Kyobutungi, Martin K. Mutua, Alex EzehAbstract:Objective To measure whether there was an association between the introduction of an output-based Voucher Programme and the odds of a facility-based delivery in two Nairobi informal settlements. Data sources Nairobi Urban Health and Demographic Surveillance System (NUHDSS) and two cross-sectional household surveys in Korogocho and Viwandani informal settlements in 2004–05 and 2006–08. Methods Odds of facility-based delivery were estimated before and after introduction of an output-based Voucher. Supporting NUHDSS data were used to determine whether any trend in maternal health care was coincident with immunizations, a non-Voucher outpatient service. As part of NUHDSS, households in Korogocho and Viwandani reported place of delivery and the presence of a skilled birth attendant (2003–10) and vaccination coverage (2003–09). A detailed maternal and child health (MCH) tool was added to NUHDSS (September 2006–10). Prospective enrolment in NUHDSS-MCH was conditional on having a newborn after September 2006. In addition to recording mother’s place of delivery, NUHDSS-MCH recorded the use of the Voucher. Findings There were significantly greater odds of a facility-based delivery among respondents during the Voucher Programme compared with similar respondents prior to Voucher launch. Testing whether unrelated outpatient care also increased, a falsification exercise found no significant increase in immunizations for children 12–23 months of age in the same period. Although the proportion completing any antenatal care (ANC) visit remained above 95% of all reported pregnancies and there was a significant increase in facility-based deliveries, the proportion of women completing 4+ ANC visits was significantly lower during the Voucher Programme. Conclusions A positive association was observed between Vouchers and facility-based deliveries in Nairobi. Although there is a need for higher quality evidence and validation in future studies, this statistically significant and policy relevant finding suggests that increases in facility-based deliveries can be achieved through output-based finance models that target subsidies to underserved populations.
Timothy Abuya - One of the best experts on this subject based on the ideXlab platform.
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initiation and continuity of maternal healthcare examining the role of Vouchers and user fee removal on maternal health service use in kenya
Health Policy and Planning, 2019Co-Authors: Mardieh Dennis, Lenka Benova, Timothy Abuya, Matteo Quartagno, Benjamin Bellows, Oona M R CampbellAbstract:This study explores the relationship between two health financing initiatives on women's progression through the maternal health continuum in Kenya: a subsidized reproductive health Voucher Programme (2006-16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the Voucher Programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the Voucher Programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P < 0.001) were also positively associated with use of continuous care among ANC users. Among continuous care users, early ANC was associated with increased odds of completing the maternal health pathway as recommended (aOR: 3.80, P < 0.001). Higher parity was negatively associated with all three outcomes, while having health insurance was positively associated with each outcome. The impact of other sociodemographic factors such as maternal age, education, wealth quintile, urban residence, and employment varied by outcome; however, the findings generally suggest that marginalized women faced greater barriers to early ANC initiation and continuity of care. Health financing and women's timing and source of ANC are strongly related to their subsequent progression through the maternal health pathway. To increase continuity of care and improve maternal health outcomes, policymakers must therefore focus on equitably reducing financial and other barriers to care seeking and improving quality of care throughout the continuum.
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Initiation and continuity of maternal healthcare: examining the role of Vouchers and user-fee removal on maternal health service use in Kenya.
Health policy and planning, 2019Co-Authors: Mardieh Dennis, Lenka Benova, Timothy Abuya, Matteo Quartagno, Benjamin Bellows, Oona M R CampbellAbstract:This study explores the relationship between two health financing initiatives on women's progression through the maternal health continuum in Kenya: a subsidized reproductive health Voucher Programme (2006-16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the Voucher Programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the Voucher Programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P
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evaluating the impact of a maternal health Voucher Programme on service use before and after the introduction of free maternity services in kenya a quasi experimental study
BMJ Global Health, 2018Co-Authors: Mardieh Dennis, Oona M R Campbell, Lenka Benova, Timothy Abuya, Matteo Quartagno, Angela Baschieri, Benjamin BellowsAbstract:Introduction From 2006 to 2016, the Government of Kenya implemented a reproductive health Voucher Programme in select counties, providing poor women subsidised access to public and private sector care. In June 2013, the government introduced a policy calling for free maternity services to be provided in all public facilities. The concurrent implementation of these interventions presents an opportunity to provide new insights into how users adapt to a changing health financing and service provision landscape. Methods We used data from three cross-sectional surveys to assess changes over time in use of 4+ antenatal care visits, facility delivery, postnatal care and maternal healthcare across the continuum among a sample of predominantly poor women in six counties. We conducted a difference-in-differences analysis to estimate the impact of the Voucher Programme on these outcomes, and whether Programme impact changed after free maternity services were introduced. Results Between the preintervention/roll-out phase and full implementation, the Voucher Programme was associated with a 5.5% greater absolute increase in use of facility delivery and substantial increases in use of the private sector for all services. After free maternity services were introduced, the Voucher Programme was associated with a 5.7% higher absolute increase in use of the recommended package of maternal health services; however, disparities in access to facility births between Voucher and comparison counties declined. Increased use of private sector services by women in Voucher counties accounts for their greater access to care across the continuum. Conclusions Our findings show that the Voucher Programme is associated with a modest increase in women’s use of the full continuum of maternal health services at the recommended timings after free maternity services were introduced. The greater use of private sector services in Voucher counties also suggests that there is need to expand women’s access to acceptable and affordable providers.
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Safe motherhood Voucher Programme coverage of health facility deliveries among poor women in South-western Uganda
Health Policy and Planning, 2013Co-Authors: Lucy Kanya, Timothy Abuya, Francis Obare, Charlotte E. Warren, Ian Askew, Benjamin BellowsAbstract:There has been increased interest in and experimentation with demand-side mechanisms such as the use of Vouchers that place purchasing power in the hands of targeted consumers to improve the uptake of healthcare services in low-income settings. A key measure of the success of such interventions is the extent to which the Programmes have succeeded in reaching the target populations. This article estimates the coverage of facility deliveries by a maternal health Voucher Programme in South-western Uganda and examines whether such coverage is correlated with district-level characteristics such as poverty density and the number of contracted facilities. Analysis entails estimating the Voucher coverage of health facility deliveries among the general population and poor population (PP) using Programme data for 2010, which was the most complete calendar year of implementation of the Uganda safe motherhood (SM) Voucher Programme. The results show that: (1) the Programme paid for 38% of estimated deliveries among the PP in the targeted districts, (2) there was a significant negative correlation between the poverty density in a district and proportions of births to poor women that were covered by the Programme and (3) improving coverage of health facility deliveries for poor women is dependent upon increasing the sales and redemption rates. The findings suggest that to the extent that the Programme stimulated demand for SM services by new users, it has the potential of increasing facility-based births among poor women in the region. In addition, the significant negative correlation between the poverty density and the proportions of facility-based births to poor women that are covered by the Voucher Programme suggests that there is need to increase both Voucher sales and the rate of redemption to improve coverage in districts with high levels of poverty.
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Population-level impact of Vouchers on access to health facility delivery for women in Kenya: a quasi-experimental study
The Lancet, 2013Co-Authors: Francis Obare, Timothy Abuya, Charlotte E. Warren, Ian Askew, Benjamin BellowsAbstract:Abstract 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 non-accredited 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. Funding The reproductive health Vouchers Programme is implemented by the Government of Kenya with major funding from the German Development Bank. The evaluation project was funded by the Bill & Melinda Gates Foundation.
Oona M R Campbell - One of the best experts on this subject based on the ideXlab platform.
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initiation and continuity of maternal healthcare examining the role of Vouchers and user fee removal on maternal health service use in kenya
Health Policy and Planning, 2019Co-Authors: Mardieh Dennis, Lenka Benova, Timothy Abuya, Matteo Quartagno, Benjamin Bellows, Oona M R CampbellAbstract:This study explores the relationship between two health financing initiatives on women's progression through the maternal health continuum in Kenya: a subsidized reproductive health Voucher Programme (2006-16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the Voucher Programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the Voucher Programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P < 0.001) were also positively associated with use of continuous care among ANC users. Among continuous care users, early ANC was associated with increased odds of completing the maternal health pathway as recommended (aOR: 3.80, P < 0.001). Higher parity was negatively associated with all three outcomes, while having health insurance was positively associated with each outcome. The impact of other sociodemographic factors such as maternal age, education, wealth quintile, urban residence, and employment varied by outcome; however, the findings generally suggest that marginalized women faced greater barriers to early ANC initiation and continuity of care. Health financing and women's timing and source of ANC are strongly related to their subsequent progression through the maternal health pathway. To increase continuity of care and improve maternal health outcomes, policymakers must therefore focus on equitably reducing financial and other barriers to care seeking and improving quality of care throughout the continuum.
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Initiation and continuity of maternal healthcare: examining the role of Vouchers and user-fee removal on maternal health service use in Kenya.
Health policy and planning, 2019Co-Authors: Mardieh Dennis, Lenka Benova, Timothy Abuya, Matteo Quartagno, Benjamin Bellows, Oona M R CampbellAbstract:This study explores the relationship between two health financing initiatives on women's progression through the maternal health continuum in Kenya: a subsidized reproductive health Voucher Programme (2006-16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the Voucher Programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the Voucher Programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P
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evaluating the impact of a maternal health Voucher Programme on service use before and after the introduction of free maternity services in kenya a quasi experimental study
BMJ Global Health, 2018Co-Authors: Mardieh Dennis, Oona M R Campbell, Lenka Benova, Timothy Abuya, Matteo Quartagno, Angela Baschieri, Benjamin BellowsAbstract:Introduction From 2006 to 2016, the Government of Kenya implemented a reproductive health Voucher Programme in select counties, providing poor women subsidised access to public and private sector care. In June 2013, the government introduced a policy calling for free maternity services to be provided in all public facilities. The concurrent implementation of these interventions presents an opportunity to provide new insights into how users adapt to a changing health financing and service provision landscape. Methods We used data from three cross-sectional surveys to assess changes over time in use of 4+ antenatal care visits, facility delivery, postnatal care and maternal healthcare across the continuum among a sample of predominantly poor women in six counties. We conducted a difference-in-differences analysis to estimate the impact of the Voucher Programme on these outcomes, and whether Programme impact changed after free maternity services were introduced. Results Between the preintervention/roll-out phase and full implementation, the Voucher Programme was associated with a 5.5% greater absolute increase in use of facility delivery and substantial increases in use of the private sector for all services. After free maternity services were introduced, the Voucher Programme was associated with a 5.7% higher absolute increase in use of the recommended package of maternal health services; however, disparities in access to facility births between Voucher and comparison counties declined. Increased use of private sector services by women in Voucher counties accounts for their greater access to care across the continuum. Conclusions Our findings show that the Voucher Programme is associated with a modest increase in women’s use of the full continuum of maternal health services at the recommended timings after free maternity services were introduced. The greater use of private sector services in Voucher counties also suggests that there is need to expand women’s access to acceptable and affordable providers.
Francis Obare - One of the best experts on this subject based on the ideXlab platform.
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Estimating willingness to pay for maternal health services: the Kenya reproductive health Voucher Programme
2015Co-Authors: Lucy Kanya, Benjamin Bellows, Francis Obare, Brian Mdawida, Charlotte E. Warren, Ian AskewAbstract:The reproductive health Voucher Programme is implemented by the Government of Kenya with major funding from the German Development Bank (KfW). The evaluation project was funded by the Bill & Melinda Gates Foundation and implemented by the Population Council in collaboration with the National Council for Population and Development (NCPD), the Ministry of Health and PriceWaterhouseCoopers.
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Safe motherhood Voucher Programme coverage of health facility deliveries among poor women in South-western Uganda
Health Policy and Planning, 2013Co-Authors: Lucy Kanya, Timothy Abuya, Francis Obare, Charlotte E. Warren, Ian Askew, Benjamin BellowsAbstract:There has been increased interest in and experimentation with demand-side mechanisms such as the use of Vouchers that place purchasing power in the hands of targeted consumers to improve the uptake of healthcare services in low-income settings. A key measure of the success of such interventions is the extent to which the Programmes have succeeded in reaching the target populations. This article estimates the coverage of facility deliveries by a maternal health Voucher Programme in South-western Uganda and examines whether such coverage is correlated with district-level characteristics such as poverty density and the number of contracted facilities. Analysis entails estimating the Voucher coverage of health facility deliveries among the general population and poor population (PP) using Programme data for 2010, which was the most complete calendar year of implementation of the Uganda safe motherhood (SM) Voucher Programme. The results show that: (1) the Programme paid for 38% of estimated deliveries among the PP in the targeted districts, (2) there was a significant negative correlation between the poverty density in a district and proportions of births to poor women that were covered by the Programme and (3) improving coverage of health facility deliveries for poor women is dependent upon increasing the sales and redemption rates. The findings suggest that to the extent that the Programme stimulated demand for SM services by new users, it has the potential of increasing facility-based births among poor women in the region. In addition, the significant negative correlation between the poverty density and the proportions of facility-based births to poor women that are covered by the Voucher Programme suggests that there is need to increase both Voucher sales and the rate of redemption to improve coverage in districts with high levels of poverty.
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Population-level impact of Vouchers on access to health facility delivery for women in Kenya: a quasi-experimental study
The Lancet, 2013Co-Authors: Francis Obare, Timothy Abuya, Charlotte E. Warren, Ian Askew, Benjamin BellowsAbstract:Abstract 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 non-accredited 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. Funding The reproductive health Vouchers Programme is implemented by the Government of Kenya with major funding from the German Development Bank. The evaluation project was funded by the Bill & Melinda Gates Foundation.
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Community-level impact of the reproductive health Vouchers Programme on service utilization in Kenya.
Health policy and planning, 2012Co-Authors: Francis Obare, Timothy Abuya, Charlotte E. Warren, Ian Askew, Rebecca Njuki, Joseph Sunday, Benjamin BellowsAbstract:This paper examines community-level association between exposure to the reproductive health Vouchers Programme in Kenya and utilization of services. The data are from a household survey conducted among 2527 women (15–49 years) from Voucher and comparable non-Voucher sites. Analysis entails cross-tabulations with Chi-square tests and significant tests of proportions as well as estimation of multi-level logit models to predict service utilization by exposure to the Programme. The results show that for births occurring after the Voucher Programme began, women from communities that had been exposed to the Programme since 2006 were significantly more likely to have delivered at a health facility and to have received skilled care during delivery compared with those from communities that had not been exposed to the Programme at all. There were, however, no significant differences in the timing of first trimester utilization of antenatal care (ANC) and making four or more ANC visits by exposure to the Programme. In addition, poor women were significantly less likely to have used safe motherhood services (health facility delivery, skilled delivery care and postnatal care) compared with their non-poor counterparts regardless of exposure to the Programme. Nonetheless, a significantly higher proportion of poor women from communities that had been exposed to the Programme since 2006 used the services compared with their poor counterparts from communities that had not been exposed to the Programme at all. The findings suggest that the Programme is associated with increased health facility deliveries and skilled delivery care especially among poor women. However, it has had limited community-level impact on the first trimester timing of antenatal care use and making four or more visits, which remain a challenge despite the high proportion of women in the country that make at least one antenatal care visit during pregnancy.
