How and why do vouchers increase uptake of Sexual Reproductive Health Services among adolescents in Kenya  

Background In Kenya, adolescents aged 15-19 constitute 24% of population. Many experience sexual and reproductive health (SRH) problems: one in every five is pregnant or has a child (Kenya Demographic Health Survey - KDHS 2014); they suffer high rates of unsafe abortions; and their maternal mortality rate is twice as high as older age groups (Ministry of Health 2018). Adolescents face a myriad of barriers accessing SRH services on both the demand- and supply side. Apart from lack of financial means, girls lack practical information, have insufficient knowledge of contraceptive methods; feel disempowered and have concerns about confidentiality. On the supply-side, providers are often unwilling to provide SRH services to adolescents, with fears of legal implications or parental disapproval. Providers have insufficient experience and knowledge on how to provide quality adolescents’ SRH services and to make their clinic youth-friendly. Health vouchers are both a financing mechanism to improve equity, as well as a programmatic tool to reduce access barriers on both the supply- and demand-side and increase use of critical services. Vouchers – paper voucher and/or e-code or other token – can be distributed to target populations who exchange them for services at accredited health providers. Providers are paid for each voucher redeemed. Program intervention In 2016 Marie Stopes Kenya (MSK) initiated a multi-component youth programme. In one component, providers from it’s socially franchised (SF) private provider network (“AMUA”) are trained in youth-friendly services. In selected AMUA clinics vouchers are implemented. Clinics are selected using a programme tool assessing youth-friendliness. MSK is the voucher management agency. The voucher package enables recipients to access multiple services including counselling, short- and long-acting contraceptives (STMs/LARCs), pregnancy tests, STI services, follow-up consultations and LARC removal. Vouchers are distributed by community health volunteers (CHVs) who receive a performance based payment for each voucher used. Providers and CHW are paid monthly. Methodology The AMUA SF network currently comprises 338 clinics spread across Kenya, the majority being situated in peri-urban and rural areas. Vouchers are implemented in 124 AMUA clinics in Nairobi, Coast, Central and Western regions. After a small pilot in Nairobi the voucher programme started in April 2017 and quickly scaled to the 124 voucher clinics in four months. Distributors collect beneficiary data and send these to a web-based voucher platform using a smartphone and obtaining a unique e-code which is written on the paper voucher. At the service delivery point, the provider validates the e-code through SMS and after service provision reports services to the platform using SMS. Service data obtained from the voucher platform and the AMUA Information System were analysed using descriptive statistics. The average monthly proportion of adolescent clients in the 12 months preceding the voucher programme is compared with the 10 months post-initiation, and these data are also compared with the 214 AMUA clinics not participating (‘controls’). Use of implants by adolescents is also compared between voucher clinics and control clinics. Results The monthly average proportion of clients being an adolescent in AMUA clinics participating in the voucher scheme quadrupled: from on average 8% in the 12 months before vouchers started to 34% in the subsequent ten months. In control clinics, these proportions remained almost the same, respectively 8% and 9%. Almost all increases observed in participating AMUA clinics were due to vouchers users: the number of fee-paying adolescents remained almost the same. In absolute numbers, the average number of adolescents making use of SRH services in the whole AMUA channel in Kenya increased from around 1,500 adolescent clients per month in the 12 months before the voucher programme started to 7,300 each month in the 10 months post-initiation. 84% of voucher users had never previously used contraceptives. Most voucher users were single (89%) and had no children (75%). Vouchers also expanded the contraceptive method choice. Implants are expensive for adolescents and while 61% of voucher users accessed an implant, in the control clinics only 32% choose an implant. However, both proportions are still high when compared with 6% use of implants among sexually active unmarried adolescents reported by KDHS 2014. Seven percent of adolescents used their voucher for IUD, again high when compared with 0% reported in the KDHS; 11% to access injectables and only 2% to obtain pills. Program implications Vouchers successfully increased SRH uptake and enabled a new group – sexually active unmarried adolescents – to access services, a group which usually faces many access barriers. Vouchers are hypothesized to not only reduce financial barriers but also other barriers on both the supply- and demand-side. Results of Kenya vouchers support this assumption. Voucher-income motivates providers to improve quality and respond better to clients’ needs, a process which is strengthened when combined with SF. On the demand-side, the voucher breaks down informational, educational, and cultural barriers and empowers youth to access services. In Kenya MSK identified factors for success: providers overcoming fear and gaining skills to counsel adolescents; motivated by voucher-income, facilities created youth spaces, expanded opening-hours, organised health talks at schools and youth events; trusted CHVs provided face-to-face counselling; performance-based payments motivated CHVs to involve community leaders, organise mobilisation activities and escort adolescents to clinics. The paper voucher itself empowered and was a discreet way to avoid explaining reason of clinic-visit (highly appreciated). In terms of sustainability, vouchers promoted sustainable change in health-seeking behaviour; when more adolescents experience contraceptive benefits, community awareness and acceptance increases; and unintended pregnancies reduce. While some research has noted potential fraud with vouchers the electronic voucher management system meant that fraud was quickly visible and controlled easily through an appropriate monitoring framework. Lastly, vouchers are a precursor towards health insurance; currently the national health insurance is looking at coverage of school-going adolescents, while MSK assists in developing youth-friendly accreditation criteria and an appropriate benefit package.