Community-level effect of the reproductive health vouchers program on out-of-pocket spending on family planning and safe motherhood services in Kenya

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

Does health voucher intervention increase antenatal consultations and skilled birth attendances in Cameroon? Results from an interrupted time series analysis

BACKGROUND

Limited access to health services during the antenatal period and during childbirth, due to financial barriers, is an obstacle to reducing maternal and child mortality. To improve the use of health services in the three regions of Cameroon, which have the worst reproductive, maternal, neonatal, child and adolescent health indicators, a health voucher project aiming to reduce financial barriers has been progressively implemented since 2015 in these three regions. Our research aimed to assess the impact of the voucher scheme on first antenatal consultation (ANC) and skilled birth attendance (SBA).

METHODS

Routine aggregated data by month over the period January 2013 to May 2018 for each of the 33 and 37 health facilities included in the study sample were used to measure the effect of the voucher project on the first ANC and SBA, respectively. We estimated changes attributable to the intervention in terms of the levels of outcome indicators immediately after the start of the project and over time using an interrupted time series regression. A meta-analysis was used to obtain the overall estimates.

RESULTS

Overall, the voucher project contributed to an immediate and statistically significant increase, one month after the start of the project, in the monthly number of ANCs (by 26%) and the monthly number of SBAs (by 57%). Compared to the period before the start of the project, a statistically significant monthly increase was observed during the project implementation for SBAs but not for the first ANCs. The results at the level of health facilities (HFs) were mixed. Some HFs experienced an improvement, while others were faced with the status quo or a decrease.

CONCLUSIONS

Unlike SBAs, the voucher project in Cameroon had mixed results in improving first ANCs. These limited effects were likely the consequence of poor design and implementation challenges.

Out-of-pocket payments during childbirth in Kenya under the free maternity services: Perspectives of mothers, healthcare workers and county officials

Background: This study seeks to determine the extent of women's out-of-pocket (OOP) payments for delivery under the free maternity policy (FMP).  Methods: We conducted a convergent parallel mixed-methods study using quantitative and qualitative data collection. The study was set in three facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved exit interview (EI) surveys with mothers (n = 553) who utilised FMP delivery services and focus group discussions (FGDs) with mothers who returned for postnatal visits (6, 10, and 14 weeks). There were 21 in-depth interviews (IDIs) with county officials and healthcare workers (HCWs). Quantitative data were analysed using descriptive statistics, while qualitative data were audio-recorded, transcribed and analysed using thematic analysis.  Results: Despite the FMP being free on paper, mothers incurred OOP payments in practice. The overall mean OOP payments incurred by mothers who underwent normal delivery was 9.50 USD (SD 8.20 USD), and caesarean section (CS) was 10.88 USD (SD 15.16 USD). The main cost drivers were transport, lack of adequate supply and medications, lack of policy clarity by health workers, failure to notify the NHIF office of available clients, and ultrasound scan services. While the OOP payments were not deemed catastrophic, some women perceived it as a barrier to care as they ended up using savings or selling their assets to meet the costs. There were no patient characteristics associated with OOP payments.  Conclusions: OOP payments during childbirth in Kenya place a considerable economic burden on mothers and their households. There is need to promote awareness of the policy and provide a sustainable form of transport, especially during emergencies, through collaboration with partners. Prioritising the supply of required medication used in maternal services in the universal health care benefits package to which Kenyan citizens are entitled, or sustainably financing the FMP is crucial.

Designing a Logic Model for Mobile Maternal Health e-Voucher Programs in Low- and Middle-Income Countries: An Interpretive Review

Despite the increasing transition from paper vouchers to mobile e-vouchers for maternal health in low- and middle-income countries, few studies have reviewed key elements for program planning, implementation, and evaluation. To bridge this gap, this study conducted an interpretive review and developed a logic model for mobile maternal health e-voucher programs. Pubmed, EMBASE, and Cochrane databases were searched to retrieve relevant studies; 27 maternal health voucher programs from 84 studies were identified, and key elements for the logic model were retrieved and organized systematically. Some of the elements identified have the potential to be improved greatly by shifting to mobile e-vouchers, such as payment via mobile money or electronic claims processing and data entry for registration. The advantages of transitioning to mobile e-voucher identified from the logic model can be summarized as scalability, transparency, and flexibility. The present study contributes to the literature by providing insights into program planning, implementation, and evaluation for mobile maternal health e-voucher programs.

Who pays and how much? A cross-sectional study of out-of-pocket payment for modern contraception in Kenya

OBJECTIVES

Out-of-pocket (OOP) payment for modern contraception is an understudied component of healthcare financing in countries like Kenya, where wealth gradients in met need have prompted efforts to expand access to free contraception. This study aims to examine whether, among public sector providers, the poor are more likely to receive free contraception and to compare how OOP payment for injectables and implants-two popular methods-differs by public/private provider type and user's sociodemographic characteristics.

DESIGN, SETTING AND PARTICIPANTS

Secondary analyses of nationally representative, cross-sectional household data from the 2014 Kenya Demographic and Health Survey. Respondents were women of reproductive age (15-49 years). The sample comprised 5717 current modern contraception users, including 2691 injectable and 1073 implant users with non-missing expenditure values.

MAIN OUTCOME

Respondent's self-reported source and payment to obtain their current modern contraceptive method.

METHODS

We used multivariable logistic regression to examine predictors of free public sector contraception and compared average expenditure for injectable and implant. Quintile ratios examined progressivity of non-zero expenditure by wealth.

RESULTS

Half of public sector users reported free contraception; this varied considerably by method and region. Users of implants, condoms, pills and intrauterine devices were all more likely to report receiving their method for free (p<0.001) compared with injectable users. The poorest were as likely to pay for contraception as the wealthiest users at public providers (OR: 1.10, 95% CI: 0.64 to 1.91). Across all providers, among users with non-zero expenditure, injectable and implant users reported a mean OOP payment of Kenyan shillings (KES) 80 (US$0.91), 95% CI: KES 78 to 82 and KES 378 (US$4.31), 95% CI: KES 327 to 429, respectively. In the public sector, expenditure was pro-poor for injectable users yet weakly pro-rich for implant users.

CONCLUSIONS

More attention is needed to targeting subsidies to the poorest and ensuring government facilities are equipped to cope with lost user fee revenue.

Meeting need vs. sharing the market: a systematic review of methods to measure the use of private sector family planning and childbirth services in sub-Saharan Africa

BACKGROUND

Ensuring universal access to maternal and reproductive health services is critical to the success of global efforts to reduce poverty and inequality. Engaging private providers has been proposed as a strategy for increasing access to healthcare in low- and middle-income countries; however, little consensus exists on how to estimate the extent of private sector use. Using research from sub-Saharan Africa, this study systematically compares and critiques quantitative measures of private sector family planning and childbirth service use and synthesizes evidence on the role of the private sector in the region.

METHODS

We conducted a systematic review of the Medline, Global Health, and Popline databases. All studies that estimated use of private sector of family planning or childbirth services in one or more sub-Saharan African countries were included in this review. For each study, we extracted data on the key study outcomes and information on the methods used to estimate private sector use.

RESULTS

Fifty-three papers met our inclusion criteria; 31 provided outcomes on family planning, and 26 provided childbirth service outcomes. We found substantial methodological variation between studies; for instance, while some reported on service use from any private sector source, others distinguished private sector providers either by their profit orientation or position within or outside the formal medical sector. Additionally, studies measured the use of private sector services differently, with some estimating the proportion of need met by the private sector and others examining the sector's share among the market of service users. Overall, the estimates suggest that the private sector makes up a considerable portion (> 20%) of the market for family planning and childbirth care, but its role in meeting women's need for these services is fairly low (< 10%).

CONCLUSIONS

Many studies have examined the extent of private sector family planning and childbirth service provision; however, inconsistent methodologies make it difficult to compare results across studies and contexts. Policymakers should consider the implications of both private market share and coverage estimates, and be cautious in interpreting data on the scale of private sector health service provision without a clear understanding of the methodology.

Assessing the community-level impact of a decade of user fee policy shifts on health facility deliveries in Kenya, 2003-2014

Background

The long-term impact of user fee removal policies on health service utilization in low- and middle-income countries may vary depending on the context in which they are implemented, including whether there are policy actions to support implementation. We examined the community-level impact of a decade of user fee policy shifts on health facility delivery among poorest and rural women and compared the changes with those among the richest and urban women in Kenya using data from three rounds of nationally representative surveys.

Methods

Data are from births occurring in the 5 years preceding the survey to women aged 15-49 years who were interviewed in the 2003, 2008-2009 and 2014 Kenya Demographic and Health Surveys. A total of 5949, 6079 and 20,964 births were reported in respective surveys. We conducted interrupted time series analysis predicting changes in quarterly proportions of births occurring in public and private health facilities as well as at home before and after the 2004, 2007 and 2013 user fee policy shifts in Kenya.

Results

There were no statistically significant immediate changes in the proportion of births occurring in public facilities following the 2004, 2007 and 2013 user fee policy shifts among poor or rural women. There was, however, a statistically significant increase in home deliveries among all women and among those from the poorest households immediately following the 2004 policy. There was also a statistically significant increase in public facility deliveries among women from the two top quintiles, which was accompanied by a statistically decline in home deliveries immediately after the 2007 policy shift. Differences in trends in public facility deliveries between pre- and post-policy periods were not statistically significant for all sub-groups of women, indicating that even among the sub-group that experienced significant immediate increase after the 2007 policy shift, this pattern was not sustained over time.

Conclusion

The findings of this paper provide empirical evidence that poorly implemented user fee removal policies benefit more well-off than poor women and in cases where there are significant immediate effects on uptake of facility delivery, this trend is not sustained over time.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0774-4) contains supplementary material, which is available to authorized users.

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

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.

Summer Weight Gain and Fitness Loss: Causes and Potential Solutions

Over the past 3 decades, public health professionals have worked to stem the rising childhood obesity epidemic. Despite the field's best efforts, no progress has been made in reducing child obesity. One reason for this failure may be that obesity prevention and treatment efforts have predominately been delivered during the 9-month school year. However, recent evidence suggests that the summer, not the school year, is when unhealthy changes in body composition (ie, accelerated increases in percent body fat) and fitness losses occur. This unhealthy change in body composition and fitness loss during the summer could be explained by the "Structured Days Hypothesis," which posits that children engage in a greater number of unhealthy obesogenic behaviors on unstructured days when compared with structured days. Furthermore, the summer may be contributing to a widening "health gap" between children from low-income and middle- to upper-income families. During summer, fewer opportunities exist for children from low-income households to access healthy structured programs that do not require fees for participation. Moving forward, public health professionals should prioritize efforts to mitigate unhealthy changes in body composition and fitness loss during the summer by identifying ways to provide access to structured programming during this timeframe for children from low-income households.

Socioeconomic status can affect pregnancy outcomes and complications, even with a universal healthcare system

Background

Low socioeconomic status can increase the risk of adverse pregnancy outcomes, but it remains unclear whether this negative association is attributed to inadequate prenatal care. Korea has been adopting a universal healthcare system. All Korean citizens must be enrolled National Health Insurance (NHI) or be recipient of Medical Aid (MA). In addition, Korean government launched a financial support system for antenatal care for all pregnant women in 2008. Therefore, in theory, there is no financial barrier to receive prenatal cares regardless of someone’s social class. However, it is still unclear whether adverse pregnancy outcomes observed in low-income women are attributable to low SES or to economic barriers specific to the utilization of medical services. The purpose of this study was to investigate whether socioeconomic status affects pregnancy outcomes after the introduction of this support system, which allows all pregnant women to receive adequate prenatal care regardless of socioeconomic status.

Methods

Using the National Health Insurance database in Korea, we selected women who gave birth between January 1, 2010 and December 31, 2010. As a proxy indicator reflecting socioeconomic status, we classified subjects as MA recipient (“low” SES) or a NHI beneficiary (“middle/high” SES).

Results

In the MA group, 29.4% women received inadequate prenatal care, compared to 11.4% in the NHI group. Mothers in the MA group were more likely to have an abortion (30.1%), rather than deliver a baby, than those in the NHI group (20.7%, P < 0.001). Mothers in the MA group were also more likely to undergo a Caesarean delivery (45.8%; NHI group: 39.6%, P < 0.001), and have preeclampsia (1.5%; NHI group: 0.6%, P < 0.001), obstetric hemorrhage (4.7%; NHI group: 3.9%, P = 0.017), and a preterm delivery (2.1%; NHI group: 1.4%, P < 0.001) than those in the NHI group.

Conclusions

Women in the MA group tended to show higher rates of abortion, Caesarean delivery, preeclampsia, preterm delivery, and obstetrical hemorrhage than those in the NHI group Therefore, health authorities should consider investigating what kind of barriers exist or what factors may affect these inequitable outcomes.