Population-level impact of vouchers on access to health facility delivery for women in Kenya

Background: Available evidence indicates that vouchers improve service utilization among the target populations. A key question is whether increased utilization results from improved access or from shifting clients from non-accredited to contracted service providers. This paper examines whether the safe motherhood voucher program in Kenya is associated with improved access to health facility delivery over time using information on births within two years preceding the survey in voucher and comparison sites. Methods: Data were collected in 2010-2011 and in 2012 among 2,933 and 3,094 women aged 15-49 years reporting 962 and 1,494 births within two years before the respective surveys. Analysis entails cross-tabulations and estimation of multilevel random-intercept logit models. Results: The proportion of births occurring at home declined by more than 10 percentage points while the proportion of births delivered in health facilities increased by a similar margin over time in voucher sites. The increase in facility-based births was consistent across public and private health facilities. There was also significant increase in the likelihood of facility-based delivery (odds ratios [OR]: 2.04; 95% confidence interval [CI]: 1.40 – 2.98 in the 2006 voucher arm; OR: 1.72; 95% CI: 1.22 – 2.43 in the 2010-2011 voucher arm) which was accompanied by significant decline in home-based births in voucher sites over time. In contrast, there were no significant changes in the likelihood of facility or home-based delivery in the comparison sites over time. Conclusion: The voucher program contributed to improved access to institutional delivery by shifting births from home to health facilities.