Background
Introduction
Healthcare expenditure in Kenya
Year | Healthcare expenditure as percentage of gross domestic product (%) | Government spending on healthcare as percentage of general government expenditure (%) | ||||
---|---|---|---|---|---|---|
Kenya | Uganda | Tanzania | Kenya | Uganda | Tanzania | |
1996 | 4.1 | 5.5 | 3.4 | 7.3 | 9.8 | 10.2 |
1999 | 4.2 | 6.7 | 3.2 | 8.3 | 11.3 | 10.2 |
2002 | 4.5 | 7.5 | 3.4 | 8.3 | 9.7 | 11.1 |
2005 | 4.4 | 9.2 | 4.0 | 7.6 | 11.2 | 8.7 |
2008 | 4.2 | 8.8 | 5.4 | 6.1 | 9.5 | 16.0 |
2011 | 4.5 | 9.5 | 7.3 | 5.9 | 10.8 | 11.1 |
Kenya reproductive health vouchers program
Methods
Study design
Data
Analysis
Variable definition | Measurement |
---|---|
Outcome variables | |
Paid for family planning services | 0 = No; |
1 = Yes | |
Paid for antenatal care services | 0 = No |
1 = Yes | |
Paid for delivery services | 0 = No |
1 = Yes | |
Paid for postnatal care services | 0 = No |
1 = Yes | |
Amount paid for family planning services | Continuous (ranges from KSh. 0 to KSh. 2,500) |
Amount paid for antenatal care services | Continuous (ranges from KSh. 0 to KSh. 20,000) |
Amount paid for delivery services | Continuous (ranges from KSh. 0 to KSh. 32,000) |
Amount paid for postnatal care services | Continuous (ranges from KSh. 0 to KSh. 20,000) |
Covariates | |
Study site | 0 = Non-voucher sites |
1 = Voucher sites | |
Study round | 0 = 2010–2011 survey |
1 = 2012 survey | |
Study round × Study site | Interaction term between study round and study site |
Maternal age at birth of child | Single years (ranges from 14 to 48); included in models for safe motherhood services |
Current age of respondent | Single years (ranges from 15 to 49); included in models for family planning services |
Education level | 0 = No schooling/pre-unit/primary |
1 = Secondary and above | |
Current marital status | 0 = Never/formerly married |
1 = Married/living together | |
Type of place of residence | 0 = Urban |
1 = Rural | |
Duration of residence | 0 = Less than 5 years/visitor |
1 = 5 years or more/always | |
Religious affiliation | 0 = Catholic/Muslim/other |
1 = Protestant/other Christian | |
Poverty statusa | 0 = Non-poor (17–24 points) |
1 = Poor (8–16 points) | |
Parity | Ranges from 1 to 16 |
Place service sought | 0 = Private health facility |
1 = Public health facility |
Results
Characteristics of women
Characteristics | 2010-2011 survey | 2012 survey | ||||
---|---|---|---|---|---|---|
Voucher sites (%) | Non-voucher sites (%) | P-value | Voucher sites (%) | Non-voucher sites (%) | P-value | |
Current age (years) | p < 0.01 | p < 0.01 | ||||
15-24 | 34.4 | 28.4 | 37.7 | 27.7 | ||
25-34 | 44.8 | 45.8 | 43.9 | 47.7 | ||
35 and above | 20.4 | 25.9 | 18.0 | 24.6 | ||
Don’t know | 0.3 | 0.0 | 0.4 | 0.0 | ||
Highest education level | p < 0.01 | p < 0.01 | ||||
No schooling/pre-unit | 10.2 | 3.1 | 9.8 | 1.9 | ||
Primary | 67.3 | 67.9 | 67.0 | 65.4 | ||
Secondary and above | 22.5 | 29.0 | 23.2 | 32.7 | ||
Current marital status | p = 0.16 | p = 0.09 | ||||
Never/formerly married | 10.6 | 10.3 | 13.8 | 11.3 | ||
Married/living together | 80.3 | 82.5 | 78.6 | 81.5 | ||
Formerly married | 9.1 | 7.1 | 7.6 | 7.2 | ||
Place of residence | p < 0.01 | p < 0.01 | ||||
Urban | 19.4 | 13.0 | 17.5 | 12.7 | ||
Rural | 80.7 | 87.0 | 82.5 | 87.3 | ||
Duration of residence | p < 0.05 | p = 0.20 | ||||
Less than 5 years/visitor | 34.7 | 39.1 | 34.9 | 37.2 | ||
5 years or more/always | 65.3 | 60.9 | 65.1 | 62.8 | ||
Religious affiliation | p < 0.01 | p < 0.01 | ||||
Catholic | 24.7 | 28.6 | 24.9 | 27.1 | ||
Protestant/other Christian | 61.7 | 70.3 | 62.9 | 70.2 | ||
Muslim | 6.9 | 0.3 | 5.4 | 0.7 | ||
Traditional/no religion | 6.8 | 0.8 | 6.8 | 1.9 | ||
Poverty status | p < 0.01 | p < 0.01 | ||||
Non-poor (17–24 points) | 18.7 | 29.1 | 23.3 | 33.0 | ||
Poor (8–16 points) | 81.3 | 71.0 | 76.7 | 67.0 | ||
Parity | p = 0.69 | p = 0.42 | ||||
0 | 4.1 | 3.1 | 5.5 | 4.4 | ||
1-2 | 40.2 | 41.0 | 39.6 | 41.0 | ||
3-4 | 31.9 | 31.6 | 32.4 | 32.5 | ||
5 and above | 23.3 | 23.9 | 22.5 | 22.1 | ||
Missing | 0.5 | 0.5 | 0.0 | 0.1 | ||
Number of women | 1,742 | 1,191 | 1,808 | 1,286 |
Use of reproductive health services
Services | 2010-2011 survey | 2012 survey | ||
---|---|---|---|---|
Voucher sites (%) | Non-voucher sites (%) | Voucher sites (%) | Non-voucher sites (%) | |
Ever used family planning | (N = 1,742) | (N = 1,191) | (N = 1,808) | (N = 1,286) |
Used any method | 59.6 | 75.2** | 66.9 | 75.0** |
Used long-term methoda | 7.6 | 9.6 | 13.8 | 13.6 |
Used FP last 12 months | (N = 1,742) | (N = 1,191) | (N = 1,808) | (N = 1,286) |
Used any method | 39.2 | 54.5** | 47.9 | 52.6** |
Used long-term methoda | 5.3 | 7.1* | 10.1 | 10.3 |
Source of last FP methodb | (N = 683) | (N = 649) | (N = 866) | (N = 676) |
Public health facility | 79.7 | 76.9 | 13.4 | 16.0 |
Private health facility | 14.4 | 15.6 | 71.4 | 70.7 |
Other/missing | 6.0 | 7.6 | 15.2 | 13.3 |
Ever use of voucher | (N = 1,742) | (N = 1,191) | (N = 1,808) | (N = 1,286) |
Used safe motherhood | 15.4 | 0.0** | 43.9 | 0.0** |
Used family planning | 1.8 | 0.0** | 6.6 | 0.0** |
Used gender-based violence | 0.0 | 0.0 | 0.0 | 0.0 |
Used any voucher | 16.0 | 0.0** | 45.0 | 0.0** |
Sought antenatal care for most recent birth | 100.0(N = 588) | 100.0(N = 361) | 96.6(N = 912) | 96.5(N = 632) |
Source of antenatal care | (N = 588) | (N = 361) | (N = 881) | (N = 610) |
Public health facility | 85.0 | 87.5 | 78.9 | 89.0** |
Private health facility | 14.0 | 11.9 | 20.7 | 11.0** |
Home/other/missing | 1.0 | 0.6 | 0.5 | 0.0 |
Source of delivery care | (N = 588) | (N = 361) | (N = 912) | (N = 632) |
Public health facility | 39.0 | 41.0 | 42.3 | 43.5 |
Private health facility | 14.1 | 12.7 | 21.9 | 13.0** |
Home/other/missing | 46.9 | 46.2 | 35.8 | 43.5** |
Source of postnatal care | (N = 588) | (N = 361) | (N = 912) | (N = 632) |
Public health facility | 42.4 | 43.2 | 60.2 | 68.2** |
Private health facility | 13.8 | 11.6 | 22.5 | 13.9** |
Home/other/missing | 43.9 | 45.2 | 17.3 | 17.9 |
Changes in payment patterns for services
Indicator | Voucher sites | Non-voucher sites | ||||
---|---|---|---|---|---|---|
2010-2011 survey | 2012 survey | Change | 2010-2011 survey | 2012 survey | Change | |
Proportions paying (%) | ||||||
Family planning | 73.8(N = 598) | 71.9(N = 750) | −1.9 | 86.3(N = 546) | 85.2(N = 568) | −1.1 |
Antenatal care | 69.1(N = 433) | 42.0(N = 877) | −27.1 | 85.0(N = 267) | 85.6(N = 610) | 0.6 |
Delivery care | 66.1(N = 221) | 30.6(N = 586) | −35.5 | 92.1(N = 140) | 89.6(N = 357) | −2.5 |
Postnatal care | 27.8(N = 209) | 7.3(N = 754) | −20.5 | 26.1(N = 138) | 18.1(N = 519) | −8.0 |
Mean amount paid (KSh) | ||||||
Family planning | 50.00(N = 598) | 50.00(N = 750) | 0.00 | 61.00(N = 546) | 93.00(N = 568) | 32.00 |
Antenatal care | 136.00(N = 429) | 109.00(N = 876) | −27.00 | 178(N = 266) | 317.00(N = 606) | 139.00 |
Delivery care | 2,047.00(N = 215) | 980.00(N = 581) | −1,067.00 | 3,193.00(N = 133) | 2,696.00(N = 352) | −497.00 |
Postnatal care | 174.00(N = 204) | 18.00(N = 754) | −156.00 | 151.00(N = 137) | 78.00(N = 518) | −73.00 |
Median amount paid (KSh) | ||||||
Family planning | 30.00(N = 598) | 30.00(N = 750) | 0 | 50.00(N = 546) | 50.00(N = 568) | 0.00 |
Antenatal care | 50.00(N = 429) | 0.00(N = 876) | −50.00 | 125.00(N = 266) | 175.00(N = 606) | 50.00 |
Delivery care | 500.00(N = 215) | 0.00(N = 581) | −500.00 | 2,000.00(N = 133) | 1,500.00(N = 352) | −500.00 |
Postnatal care | 0.00(N = 204) | 0.00(N = 754) | 0.00 | 0.00(N = 137) | 0.00(N = 518) | 0.00 |
Difference-in-differences estimates
Covariates | Family planning | Antenatal care | Delivery care | Postnatal care |
---|---|---|---|---|
Study site (voucher sites = 1) | −0.12**(−0.18; −0.06) | 0.16**(−0.25; −0.06) | −0.27**(−0.37; −0.17) | −0.00(−0.11; 0.11) |
Study round (2012 survey = 1) | −0.01(−0.06; 0.04) | 0.01(−0.05; 0.06) | −0.04(−0.10; 0.02) | −0.09*(−0.17; −0.01) |
Study round × Study site | −0.01(−0.08; 0.06) | −0.27**(−0.36; −0.18) | −0.30**(−0.40; 0.19) | −0.12*(−0.22; −0.02) |
Current age (single years) | 0.00(−0.00; 0.01) | n/a | n/a | n/a |
Maternal age at last birth (single years) | n/a | 0.00(−0.01; 0.01) | 0.00(−0.00; 0.01) | −0.00(−0.01; 0.00) |
Highest education level (secondary and above = 1) | −0.02(−0.06; 0.02) | 0.01(−0.04; 0.06) | 0.12(−0.03; 0.01) | −0.04(−0.09; 0.00) |
Current marital status (married/ living together = 1) | 0.05*(0.00; 0.11) | 0.04(−0.01; 0.09) | 0.02(−0.04; 0.08) | −0.04(−0.09; 0.02) |
Type of place of residence (rural = 1) | 0.02(−0.07; 0.12) | −0.07(−0.18; 0.03) | −0.06(−0.19; 0.07) | −0.06(−0.13; 0.02) |
Duration of residence (5 or more years/always = 1) | −0.02(−0.06; 0.02) | −0.02(−0.06; 0.02) | −0.02(−0.07; 0.03) | 0.01(−0.03; 0.05) |
Religious affiliation (Protestant/ other Christian = 1) | 0.02(−0.02; 0.06) | 0.01(−0.03; 0.05) | 0.01(−0.04; 0.06) | 0.01(−0.03; 0.05) |
Poverty status (poor = 1) | −0.01(−0.05; 0.03) | −0.00(−0.04; 0.04) | 0.01(−0.04; 0.06) | 0.02(−0.06; 0.02) |
Parity | −0.02**(−0.04; −0.01) | 0.00(−0.01; 0.02) | −0.02(−0.04; 0.00) | 0.01(−0.00; 0.02) |
Facility type (public = 1) | −0.05*(−0.10; −0.00) | 0.10*(0.02; 0.18) | 0.21**(0.15; 0.28) | −0.01(−0.06; 0.04) |
Constant | 0.90**(0.76; 1.05) | 0.78**(0.61; 0.95) | 0.75**(0.54; 0.95) | 0.41**(0.23; 0.58) |
Number of cases | 2,461 | 2,179 | 1,302 | 1,618 |
Covariates | Family planning | Antenatal care | Delivery care | Postnatal care |
---|---|---|---|---|
Study site (voucher sites = 1) | −7.23(−19.82; 5.23) | −41.16(−85.39; 3.06) | −844.79(−1701.30; 11.71) | 70.39(−207.79; 348.57) |
Study round (2012 survey = 1) | 32.63**(13.90; 51.37) | 140.47**(65.13; 215.80) | −335.19(−1119.16; 448.79) | −41.61(−224.02; 140.80) |
Study round × Study site | −33.43**(−54.97; 11.88) | −172.05**(−252.65; −91.45) | −726.53(−1624.88; 171.83) | −103.93(−376.60; 168.74) |
Current age (single years) | 1.10(−0.27; 2.28) | n/a | n/a | n/a |
Maternal age at last birth (single years) | n/a | 2.79(−0.21; 6.15) | 111.02**(52.26; 169.79) | 9.30(−13.05; 31.66) |
Highest education level (secondary and above = 1) | 22.11**(5.74; 38.48) | 7.28(−42.27; 56.84) | 600.90*(126.53; 1075.27) | 58.32(17.99; 134.64) |
Current marital status (married/ living together = 1) | 3.27(−8.06; 14.59) | 47.82(−5.83; 101.47) | 169.07(−354.16; 692.31) | −69.51(−212.27; 73.25) |
Type of place of residence (rural = 1) | 8.21(−0.84; 17.26) | −55.54(−124.28; 13.19) | −303.86(−978.63; 370.92) | 37.37(−48.88; 123.62) |
Duration of residence (5 or more years/always = 1) | 0.47(−9.78; 10.72) | 60.40(−10.27; 131.08) | −160.04(−597.01; 276.93) | 7.60(−51.26; 66.46) |
Religious affiliation (Protestant/ other Christian = 1) | −0.96(−14.89; 12.97) | 5.48(−39.61; 50.56) | 13.60(−343.87; 371.08) | 50.15*(4.74; 95.56) |
Poverty status (poor = 1) | 2.12(−10.10; 14.34) | −31.70(−79.88; 16.49) | −455.64*(−888.01; −23.27) | −112.22*(−212.86; −11.57) |
Parity | −0.17(−5.50; 5.17) | −24.52**(−40.12; −8.93) | −325.94**(−485.99; −165.89) | −26.59(−82.13; 28.94) |
Facility type (public = 1) | −43.74**(−63.88; −23.59) | −90.07**(−148.14; −32.00) | −638.31*(−1238.26; −38.35) | −11.23(−101.89; 79.43) |
Constant | 50.44**(22.17; 78.70) | 244.07**(131.94; 356.20) | 1715.90*(61.13; 3370.68) | 3.19(−379.66; 386.05) |
Number of cases | 2,461 | 2,169 | 1,279 | 1,611 |