title: A cross sectional comparison of postnatal care quality in facilities participating in a maternal health voucher program versus non-voucher facilities in Kenya.
abstract: BACKGROUND
  Health service fees constitute substantial barriers for women seeking childbirth and postnatal care. In an effort to reduce health inequities, the government of Kenya in 2006 introduced the output-based approach (OBA), or voucher programme, to increase poor women's access to quality Safe Motherhood services including postnatal care. To help improve service quality, OBA programmes purchase services on behalf of the poor and marginalised, with provider reimbursements for verified services. Kenya's programme accredited health facilities in three districts as well as in two informal Nairobi settlements.
  
  
  METHODS
  Postnatal care quality in voucher health facilities (n = 21) accredited in 2006 and in similar non-voucher health facilities (n = 20) are compared with cross sectional data collected in 2010. Summary scores for quality were calculated as additive sums of specific aspects of each attribute (structure, process, outcome). Measures of effect were assessed in a linear regression model accounting for clustering at facility level. Data were analysed using Stata 11.0.
  
  
  RESULTS
  The overall quality of postnatal care is poor in voucher and non-voucher facilities, but many facilities demonstrated 'readiness' for postnatal care (structural attributes: infrastructure, equipment, supplies, staffing, training) indicated by high scores (83/111), with public voucher facilities scoring higher than public non-voucher facilities. The two groups of facilities evinced no significant differences in postnatal care mean process scores: 14.2/55 in voucher facilities versus 16.4/55 in non-voucher facilities; coefficient: -1.70 (-4.9, 1.5), p = 0.294. Significantly more newborns were seen within 48 hours (83.5% versus 72.1%: p = 0.001) and received Bacillus Calmette-Guerin (BCG) (82.5% versus 76.5%: p < 0.001) at voucher facilities than at non-voucher facilities.
  
  
  CONCLUSIONS
  Four years after facility accreditation in Kenya, scores for postnatal care quality are low in all facilities, even those with Safe Motherhood vouchers. We recommend the Kenya OBA programme review its Safe Motherhood reimbursement package and draw lessons from supply side results-based financing initiatives, to improve postnatal care quality.
authors.affiliation: Population Council, 4301 Connecticut Avenue NW, Washington DC, 20008, USA. cwarren@popcouncil.org.
authors.forename: Charlotte E
authors.initials: CE
authors.lastname: Warren
authors.affiliation: Population Council General Accident Insurance House, Ralph Bunche Road, PO Box 17643, Nairobi, 00500, Kenya. tabuya@popcouncil.org.
authors.forename: Timothy
authors.initials: T
authors.lastname: Abuya
authors.affiliation: Population Council General Accident Insurance House, Ralph Bunche Road, PO Box 17643, Nairobi, 00500, Kenya. Lucy.Kanya@brunel.ac.uk.
authors.forename: Lucy
authors.initials: L
authors.lastname: Kanya
authors.affiliation: Population Council General Accident Insurance House, Ralph Bunche Road, PO Box 17643, Nairobi, 00500, Kenya. fonyango@popcouncil.org.
authors.forename: Francis
authors.initials: F
authors.lastname: Obare
authors.affiliation: Population Council General Accident Insurance House, Ralph Bunche Road, PO Box 17643, Nairobi, 00500, Kenya. njuki.rebecca@gmail.com.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Njuki
authors.affiliation: Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Ghent University, De Pinte Laan 185, B-9000, Ghent, Belgium. Marleen.Temmerman@UGent.be.
authors.forename: Marleen
authors.initials: M
authors.lastname: Temmerman
authors.affiliation: Population Council General Accident Insurance House, Ralph Bunche Road, PO Box 17643, Nairobi, 00500, Kenya. bbellows@popcouncil.org.
authors.forename: Ben
authors.initials: B
authors.lastname: Bellows
mesh_terms: D000068:Accreditation; D000328:Adult; D003430:Cross-Sectional Studies; D005193:Family Planning Services / Q000592:standards; D005260:Female; D005380:Financing, Government; D005102:Health Expenditures; D006268:Health Facilities / Q000592:standards*; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006801:Humans; D017589:Immunization Programs / Q000592:standards; D007231:Infant, Newborn; D007630:Kenya; D008427:Maternal Health Services / Q000191:economics / Q000592:standards; D010043:Outcome and Process Assessment, Health Care; D017060:Patient Satisfaction; D011181:Postnatal Care / Q000191:economics / Q000592:standards*; D011247:Pregnancy; D011787:Quality of Health Care