Exploring the effectiveness of the output-based aid voucher program to increase uptake of gender-based violence recovery services in Kenya: A qualitative evaluation

There is increasing global concern regarding gender-based violence (GBV) as a public health issue. Worldwide, the estimated lifetime prevalence of GBV among women is between 15 and 71 percent [1‐4]. Estimates from African countries indicate a lifetime prevalence of between 25% and 48% (for example: 48% in Zambia, 47% in Kenya, 34% in Egypt, 30% in Uganda and 25% in South Africa) and an annual prevalence ranging between 10% and 26% [5‐7]. Rape and domestic violence are estimated to account for between 5 and 10 percent of healthy years lost by women [8].

Data from Kenya, for example, show that 39 percent of women aged 15–49 years have experienced some form of physical violence from the age of 15 while 45 percent have experienced either physical or sexual violence [9]. Among ever married women aged 15–49 years, 47 percent have experienced physical, sexual or emotional violence from a husband or live-in partner [9]. Over the years, the need to improve access for survivors of GBV services in sub-Saharan Africa (SSA) has received increased attention, given the reported linkage between GBV and reproductive health problems [10‐14]. GBV has, for instance, been associated with short birth intervals, increased infant mortality, under nutrition among children of abused mothers, and increased incidence of HIV/AIDS and sexually transmitted infections (STIs) [13, 15‐19].

The high rates and health effects of GBV documented in SSA have led to discussions and proposals for the integration of GBV services in innovative health financing models such as the “demand-side” health financing (DSF) or “output-based aid” (OBA). The goal of these health care financing models is to increase access to and uptake of key services by offering sufficient subsidies and resources to enable the user to purchase the service, preferably by being able to choose a provider from among a number of alternatives [20, 21].

In OBA programs, a voucher management agency (VMA) distributes or sells vouchers at a subsidized price to clients, who purchase a voucher for a specific service. OBA programs provide incentives to clients and healthcare workers and subsidize specific health care packages based on the provision of care with pre-defined quality standards and pre-determined outputs [22, 23] with the goals of improving service quality, stimulating client use of selected services, targeting services among high-priority populations (such as the poor or underserved), and containing costs [24‐28]. In some programs there is a supervisory or regulatory body that meets periodically to oversee their functioning. The structure of the OBA programs is such that it identifies and invites individual or networked service providers (public, non-profit or for-profit) to assess their suitability to participate. Those agreeing to participate can only do so if they can demonstrate service provision at a specified standard of quality of care; they are then accredited to participate subject to regular review. Usually a number of providers are accredited to create competition and give consumers choice. When the client needs the services, s/he then redeems the voucher for the specified service at one of the accredited facilities. The provider is then reimbursed service cost or paid an incentive upon submission of a claim and supporting evidence to the VMA.

In Kenya, the reproductive health voucher program was launched in 2005 with an overall aim of increasing skilled birth attendance for women seeking maternal and newborn services, increasing utilization of long-term family planning methods, and increasing the uptake of gender-based violence recovery (GBVR) services for both men and women. The program contracts both public and private facilities to provide a comprehensive reproductive health service package [29]. The OBA program is currently being implemented in five sites across five provinces in Kenya namely: Kisumu, Kitui, Kiambu, and Kilifi districts, and Korogocho and Viwandani informal settlements in Nairobi. In total 10 hospitals were accredited to provide GBVR services.

The GBVR services vouchers are made freely available to women at the facility; there is no community-based distribution and no specific selection criteria for identifying eligible clients, such as a poverty grading tool used to identify beneficiaries for family planning and safe motherhood services [20]. Each accredited facility has a stack of vouchers which is used to submit a claim after services are rendered to clients. The GBVR services vouchers provide access to a wide range of services, including: (i) a medical examination, treatment and management of injuries, hospitalization and accommodation, laboratory testing and X-rays, pregnancy prevention services and HIV post exposure prophylaxis (PEP), (ii) counseling services specifically consisting of psychological care, trauma counseling, crises management, HIV pre-and post-test counseling, and adherence counseling, and (iii) links to support groups which provide legal aid, monthly group therapy sessions for survivors of rape, information and referral for long-term shelters, and help for survivors in liaising with social services departments and private sector support for medical services.

Although the voucher program has been successful in increasing skilled birth attendance, uptake of long-acting family planning methods, and reducing out-of-pocket expenditure [30, 31], there is no evidence to date regarding the effectiveness of the voucher approach with respect to improving access to GBVR services. This paper therefore explores the extent to which the Kenya OBA GBVR services are viewed as effective from the perspectives of different actors including any perceived barriers to the use of GBVR services.

The paper draws on qualitative data including 97 in-depth interviews (IDIs) and 27 focus group discussions (FGDs). A total of 69 IDIs were conducted with health managers and service providers, three with VMA managers, and 25 with government administration officers at the district level. The FGDs were, on the other hand, held with female voucher users and non-users, voucher distributors and opinion leaders such as local village elders, chiefs and community health workers drawn from the five program sites. Qualitative data provided insight on the utilization, perceptions of and experiences with the GBVR services vouchers as well as on awareness, understanding and attitudes towards the voucher program. The FGDs consisted of between six and eight participants with discussions lasting one to two hours. The IDIs and FGDs were tape recorded and transcribed into a Microsoft Word file. The transcribed texts were then transferred to NVIVO 8 analysis software. Data analysis was done by two researchers. Following coding, a full list of themes was available for categorization within a hierarchical framework of main and sub-themes. The thematic framework was then systematically applied to all of the interview transcripts. We looked for patterns and associations of the themes and compared and contrasted within and between the different actors with specific focus on awareness and understanding of GBV vouchers and services, stigma and access barriers, opportunities and challenges for GBV program functioning and barriers for legal redress.

Ethical approval for conducting the study was granted by the Population Council Institutional Review Board and the Kenya Medical Research Institute Ethical Review Committee [32].

The views of the different actors provided important insights on the perceptions and barriers to implementation and factors affecting utilization of GBVR services subsidized by the voucher program in Kenya. It was clear from the narratives that all the actors had limited knowledge of GBVR vouchers and most recommended improving community engagement and sensitization about the voucher program. In addition, service providers and voucher distributors indicated that community members lacked assurance that the GBVR services voucher provides free services. Lack of basic information on the GBVR services prevents many survivors from seeking care or taking up other support services from medical and legal institutions.

Our findings illustrate poor community knowledge of GBVR services vouchers, the benefit package and the need for treatment. This points out to a need to improve community awareness and engagement with the GBVR services voucher program. The active participation of the local community in planning, implementing, and monitoring interventions is a crucial factor in successful implementation of any program. Recent studies have reported that bottom up designs that emphasize community-driven interventions are more successful compared to those initiated using a top down approach [33, 34]. There is an opportunity for the program to explore partnering with community organizations, women’s groups and local leaders to improve community awareness of the GBVR services voucher.

Cultural factors and stigma emerged as key barriers to the uptake of GBVR services. For instance, how to deal with cases of defilement and rape by close relatives has been noted as a key deterrent to the utilization of GBVR services. The fact that community norms and beliefs have played a role in protecting perpetrators of sexual assault cannot be underestimated. This is consistent with other studies that show cultural factors as the single most important obstacle for low utilization of health services even when a transport system is in place [35, 36]. Non-legal, community sanctioned mechanisms of addressing sexual assaults such as compensation of the family at an agreed rate or involving provincial administration officers are seen as a substitute to medical treatment which undermines utilization of GBVR services. Perceived lack of privacy and confidentiality in the entire process of seeking forensic evidence and completing P3 forms to seek medical treatment or start the legal redress process is viewed as part of disclosing information about the perpetrator. These perceived fears should be addressed to improve uptake of GBVR services through education of providers and police officers on the need for maintaining confidentiality for GBV survivors. Further, the treatment the survivors get at the first point of contact is critical but overlooked, and survivors are often humiliated. For example, police officers are reported to handle survivors poorly and consequently the majority of them give up seeking GBVR services at this point. The program should perhaps explore partnering with police officers and local community-sanctioned forums to encourage referral to facilities and access to justice.

As already noted, community referral and transport system is a key challenge in the utilization of GBVR services. A poor transport network and lack of money to pay for transport costs have been associated with delays in reaching a health facility and low utilization of the GBVR services voucher. It also has implications for the 72-hour ‘window of opportunity’ for forensic examination and medical management of survivors. The distribution point of the GBVR services voucher at the facility appears to pose a challenge especially for rural residents given that all facilities accredited to offer GBVR services are hospitals mainly located in urban areas. In addition, the survivors do not have an adequate choice of facilities from where to seek the services due to the sparse distribution of the accredited providers. The inability of the existing distribution system to effectively reach rural areas suggests the need to build capacity for lower level facilities to provide GBVR services. Whereas the voucher program provides transport and referrals for only life-threatening complications, most gender-based violence cases are not perceived as life threatening, however they do require specialized care within a specific time period. In cases of referral, failure to afford the costs means that the client will not seek the required care. Although the OBA program finances all the facility-based costs for gender-based recovery services, it does not cover transportation costs and this presents an important missed opportunity. Transportation costs within the voucher program have been noted as a major contributing factor to low utilization of reproductive health services [22, 27]. Putting in place mechanisms for transport reimbursement could potentially improve GBVR services uptake within the voucher program.

Although one aim of the voucher program is to encourage provision of quality care, this is being undermined by facilities with service providers who are not competent to provide GBVR services, and a lack of supplies and equipment. Furthermore, many service providers do not understand the GBVR services benefit package. To achieve program objectives, quality care should be improved through capacity building of providers to offer GBVR services. There is also need for strengthening the health system. The program has an opportunity for working closely with local community health workers and midwives to provide basic treatment and speedy referrals to improve the number of GBV survivors receiving critical care within 72 hours. In addition, it appears that poor treatment of survivors by providers is a deterrent to utilization of GBVR services. For example, the majority of women and community opinion leaders maintained that in the community, a previous bad experience with a health care provider influences the choice of whether a person will seek facility treatment or not. This is consistent with findings from other studies that show that the poor treatment of clients affects health care service utilization [35].

There is a need to address the confusion among providers regarding the process required in terms of timing to seek medical management of rape and sexual violence. In Kenya, rape survivors are encouraged to first seek medical attention and immediately after report to the police. However, if survivors report to the police first, they should go to the health facility immediately after. Providers need to be sensitized that contrary to what some of them think, the P3 form does not have to be completed immediately; this can be done after the medical evaluation is complete [37]. A post-rape care form (PRC1) allows for the history taking, documentation and examination. The PRC1 form is filled by a trained clinician at health facilities to provide clinical notes that facilitate the filling of the P3 form by ensuring that all the relevant details are available. The police provide the P3 form that should be completed by an authorized health worker based on the clinical notes found in PCR1.

Overall our findings suggest a need for inter-sectorial collaboration to develop new linkages and strengthen existing ones in order to improve the uptake of GBVR services. It appears that the scarcity of referral linkages between different levels of facilities result in missed opportunities for prompt treatment. The 72-hour ‘window of opportunity’ for forensic examination and medical management requires speedy and efficient referrals. To reduce delays in seeking timely treatment, there is need to address the general confusion over protocols and procedures among different sets of players, develop effective referral mechanisms, and strengthen collaboration among facilities of different sectors.

Overall, the OBA voucher program has been shown to increase skilled birth attendance and uptake of long-term family planning methods. It is therefore imperative that barriers surrounding the uptake of the GBVR services be addressed in order to increase demand for the services. As highlighted in this paper, various factors affect the successful implementation of the GBVR services voucher program. These include access to accredited providers, difficulty in seeking justice, lack of understanding of the GBVR services voucher by target populations, perceived lack of privacy and confidentiality, the requirement to collect forensic evidence and poor handling of survivors by health care providers and the police. These findings suggest that there is a need to build the capacity of health care providers and police officers, strengthen the community strategy component of the OBA program to promote the GBVR services voucher, and conduct widespread community education programs aimed at prevention, ensuring survivors know how and where to access services and addressing stigma and cultural barriers.

In the study setting, it was difficult to recruit survivors of GBV and therefore the findings are based on general community and provider perceptions, knowledge of GBV and the GBVR services voucher. The researchers could not distinguish survivors among the study participants. In-depth interviews with the survivors could have possibly given a better perspective of the effectiveness of the OBA voucher program regarding improving access to and uptake of GBVR services. Another limitation of the study stems from the fact that participants in the IDIs and FGDs were not randomly selected, which may affect the generalization of the findings to the populations covered by the voucher program. However, the selection of participants was aimed at capturing the views of actors representing various groups of people in the community (voucher program managers, voucher distributors, service providers, the local administration, and the intended beneficiaries) with the hope that consistent themes across the groups would suggest that the issues are generalizable to the community. There is also the potential for subjectivity in the analysis and interpretation of the findings, which was addressed by having two researchers conduct the analysis and compare findings.