Payment after delivery

Germany has been supporting Kenya’s health sector for a long time. Both governments have opted to test the ­innovative approach of output-based aid in reproductive health (RH/OBA). The RH/OBA ­programme is funded by the KfW Ent­wicklungsbank on behalf of Germany’s Federal Government. It is running in three rural areas and two urban slums. The RH/OBA programme relates to the Government of Kenya’s plans to establish a National Social Health Insurance Fund.

In the trial-programme areas, vouchers for specific health services have been made available. There are three different vouchers.
– The Safe Motherhood Voucher entitles women to professional antenatal care, delivery services including Caesarian sections when needed, postnatal care for mothers and babies for six weeks after delivery, treatment of complications, referral to hospitals when needed as well as health education and counselling.
– The Family Planning Voucher entitles ­clients to long-term contraception
methods including monitoring, referral and consultation. Methods of choice include implants (Norplant/Jadelle), intra­uterine contraceptive devices (IUCD), female voluntary contraceptive surgery (bilateral tubal ligation) and male voluntary contraceptive surgery (vasectomy).
– The Gender Violence Services Voucher entitles victims to medical and surgical treatment as well as counselling.

The target group

To qualify for these vouchers, one has to be below the poverty line, as 46 % of the people in the programme areas are. The target group suffers from high unemployment and low education levels. Typically, people lack decent infrastructure and adequate sanitation facilities. Many ­women are self-employed or jobless; ­incomes tend to be low and sporadic.

The vouchers are accepted by accredited healthcare facilities, including a number of government hospitals and non-­governmental organisations. The RH/OBA programme reimburses these ­facilities after they have delivered their services. It is designed to boost the ­capacities of existing healthcare facilities by ensuring that patients have the purchasing power to buy the services they need. Since the introduction of the programme, the facilities have seen the number of clients rise. With the exception of the Gender Violence Voucher, the patients actually have to bare a fraction of the costs, but the vouchers massively subsidise their expenditure. Thanks to higher cash-flows, the healthcare facilities are in a position to invest in improving their services.

Costs and services

Members of the target group have to pay 200 Kenyan Shillings ($ 2.50) for a Safe Motherhood Voucher. This voucher covers all birth-related costs. If a Caesarean section is necessary, such costs can amount to 20,000 Shillings. In cases of complications, moreover, the covered costs are likely to be much higher.

This voucher has proved quite popular. During the first phase of the programme (July 2006 to October 2008), 66,820 women used it. In the second phase (Novem­ber 2008 to January 2011), the number dropped to 54,416. This decline was, to a considerable extent, due to more couples making use of contra­ceptives thanks to the Family Planning Voucher. The figures therefore indicate success.

The Family Planning Voucher costs 100 Shillings, but buys up to 3,000 Shillings worth of services. In the first phase, 8,835 persons used it, in the second 13,795 did. Until this programme was ­initiated, the use of contraceptives had been in decline in the RH/OBA programme areas.

It is interesting that more vouchers are sold than used. During the first phase, 25,746 Family Planning Vouchers were sold, but 16,911 of them were not used. While this discrepancy shows people’s hesitation to resort to long-term contraceptive methods, it does not invalidate the scheme. Access to family planning methods should be considered something like a human right, but long-term decisions need to be considered carefully. Apparently, people are willing to invest in the option even when they have not decided to make use of it yet and perhaps may even never do so.

The Gender Violence Voucher is free. In the first phase, this voucher was only used 352 times, but in the second phase the figure rose to 1,115 claims. Since gender-related and sexualised violence are traumatic, it is not easy to reach out to victims. The rising number of used vouchers shows that the programme is doing so successfully.

The services of the accredited facilities meet the standards defined by Kenya’s Ministry of Medical Services and Ministry of Public Health and Sanitation. The facilities are evaluated in regard to their human resources, equipment, drugs and their performance. The evaluation process points out shortcomings, thus helping the facilities to improve matters.

The healthcare facilities do not distribute the vouchers. Rather, the vouchers are sold by third-party agents. This design serves to ensure there is no embezzlement of funds. ­Independent retainers, moreover, monitor the services and regularly interview clients. They also visit the healthcare facilities and the distribution points frequently.

All summed up, this output-based aid programme is quite successful. Its acceptance is good, and people are increasingly making use of the sensitive options provided by the Family Planning Voucher and the Gender Violence Voucher.