title: Can reproductive health voucher programs improve quality of postnatal care? A quasi-experimental evaluation of Kenya's safe motherhood voucher scheme.
abstract: This study tests the group-level causal relationship between the expansion of Kenya's Safe Motherhood voucher program and changes in quality of postnatal care (PNC) provided at voucher-contracted facilities. We compare facilities accredited since program inception in 2006 (phase I) and facilities accredited since 2010-2011 (phase II) relative to comparable non-voucher facilities. PNC quality is assessed using observed clinical content processes, as well as client-reported outcome measures. Two-tailed unpaired t-tests are used to identify differences in mean process quality scores and client-reported outcome measures, comparing changes between intervention and comparison groups at the 2010 and 2012 data collection periods. Difference-in-differences analysis is used to estimate the reproductive health (RH) voucher program's causal effect on quality of care by exploiting group-level differences between voucher-accredited and non-accredited facilities in 2010 and 2012. Participation in the voucher scheme since 2006 significantly improves overall quality of postnatal care by 39% (p=0.02), where quality is defined as the observable processes or components of service provision that occur during a PNC consultation. Program participation since phase I is estimated to improve the quality of observed maternal postnatal care by 86% (p=0.02), with the largest quality improvements in counseling on family planning methods (IRR 5.0; p=0.01) and return to fertility (IRR 2.6; p=0.01). Despite improvements in maternal aspects of PNC, we find a high proportion of mothers who seek PNC are not being checked by any provider after delivery. Additional strategies will be necessary to standardize provision of packaged postnatal interventions to both mother and newborn. This study addresses an important gap in the existing RH literature by using a strong evaluation design to assess RH voucher program effectiveness on quality improvement.
authors.affiliation: Jacaranda Health, Nairobi, Kenya.
authors.forename: Claire
authors.initials: C
authors.lastname: Watt
authors.affiliation: Population Council, Nairobi, Kenya.
authors.forename: Timothy
authors.initials: T
authors.lastname: Abuya
authors.affiliation: Population Council, Washington DC, United States of America.
authors.forename: Charlotte E
authors.initials: CE
authors.lastname: Warren
authors.affiliation: Population Council, Nairobi, Kenya.
authors.forename: Francis
authors.initials: F
authors.lastname: Obare
authors.affiliation: Population Council, Nairobi, Kenya.
authors.forename: Lucy
authors.initials: L
authors.lastname: Kanya
authors.affiliation: Population Council, Nairobi, Kenya.
authors.forename: Ben
authors.initials: B
authors.lastname: Bellows
mesh_terms: D000328:Adult; D005193:Family Planning Services / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D005380:Financing, Government / Q000458:organization & administration*; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007231:Infant, Newborn; D007630:Kenya; D009035:Mothers; D011181:Postnatal Care / Q000191:economics*; D011203:Poverty; D011247:Pregnancy; D015397:Program Evaluation; D058996:Quality Improvement; D060728:Reproductive Health / Q000191:economics*; D034121:Reproductive Health Services
references.citation: Stud Fam Plann. 1990 Mar-Apr;21(2):61-91
references.pmid: 2191476
references.citation: Hum Resour Health. 2016 Mar 12;14:10
references.pmid: 26971317
references.citation: BMC Public Health. 2011 Mar 23;11:177
references.pmid: 21429207
references.citation: Lancet. 2011 Sep 24;378(9797):1139-65
references.pmid: 21937100
references.citation: BMC Public Health. 2012 Jul 23;12:540
references.pmid: 22823923
references.citation: PLoS Med. 2010 Jun 21;7(6):e1000295
references.pmid: 20574515
references.citation: Lancet. 2010 Jun 5;375(9730):2032-44
references.pmid: 20569843
references.citation: Health Policy Plan. 2011 Jan;26(1):25-32
references.pmid: 20375105
references.citation: BMC Public Health. 2011 Aug 24;11:667
references.pmid: 21864405
references.citation: Glob Health Sci Pract. 2014 Apr 08;2(2):173-81
references.pmid: 25276575
references.citation: Int J Qual Health Care. 2006 Feb;18(1):35-42
references.pmid: 16421187
references.citation: Trop Med Int Health. 2006 Jun;11(6):889-98
references.pmid: 16772011
references.citation: PLoS Med. 2010 Jun 21;7(6):e1000294
references.pmid: 20574524
references.citation: Health Policy Plan. 2014 Jul;29 Suppl 1:i4-11
references.pmid: 24173430
references.citation: BMC Public Health. 2006 Aug 07;6:204
references.pmid: 16893463
references.citation: Lancet. 2007 Oct 13;370(9595):1358-69
references.pmid: 17933651
references.citation: Soc Sci Med. 2014 Feb;102:183-9
references.pmid: 24565156
references.citation: Lancet. 2010 May 8;375(9726):1609-23
references.pmid: 20382417
references.citation: Trop Med Int Health. 2011 Jan;16(1):84-96
references.pmid: 21044235
references.citation: Proc Natl Acad Sci U S A. 2011 Feb 1;108(5):1821-6
references.pmid: 21245314
references.citation: Health Policy Plan. 2013 Mar;28(2):165-75
references.pmid: 22492923
references.citation: Trop Med Int Health. 2012 Jan;17(1):2-8
references.pmid: 21831117
references.citation: JAMA. 1988 Sep 23-30;260(12):1743-8
references.pmid: 3045356