Knowledge of vouchers benefit package and technical competence for providing the services
Our findings demonstrate different levels of awareness among healthcare providers and managers in relation to the vouchers benefit package across the facilities. Overall, facility managers had better awareness of the FP and SM services package compared to the healthcare providers. However, facility managers from the dispensary level demonstrated poor knowledge of postnatal care (PNC) services provided through the vouchers. Healthcare providers working in the dispensaries also demonstrated low levels of knowledge of PNC as well as long acting and reversible contraception (LARC) and permanent methods (PM) (LARC-PM) as a benefit package of the voucher. One healthcare provider explains as below
“They should train on the OBA program procedures. The first thing; the kind of services that they would want us to give, what the card covers for so that we don’t keep on messing then what level of service does OBA cover; where can it cover, where would it people involved. I wish they could also come in and sponsor some trainees to help in improving such as the gender sexual violence”. (IDI, Healthcare provider)
There were also differences in the knowledge of services covered under the voucher program. Health healthcare providers from the private and public sector demonstrated better knowledge of the SM and FP voucher package compared to the mission-based facilities. There was poor knowledge of GBVRS voucher benefit package across all facilities, levels and sectors. The FP voucher was not well understood by some facility managers and providers, with some stating that it covered both short and (LARC-PM) methods while majority did not know what services were covered by the GBVRS voucher.
There is a felt need by providers and managers for training in GBVRS, (LARC-PM) FP methods and reproductive health cancer screening. The following extracts demonstrate the need for more clinical training;
“We have not yet been trained into handling those sorts of things [gender based violence] so we refer it to xxxx hospital”. (IDI, healthcare provider)
“The training should provide updates on the training of implants and the IUCD and all these OBA …sterilization, voluntary surgical contraception”. (IDI, Healthcare provider)
“We need training on GBV which they promised to come and hold training with us. We still have no clear understanding of it. We have patients who come since there are cases but when we refer, we break confidentiality since we don’t have knowledge and guidelines on how to handle them [GBV cases]”. (IDI, Healthcare provider)
“They need to include other things – for example, train on counseling on how to handle rape care, which has been challenging. Also, train on the P3 forms [post-rape forms], which are not well known….also train on long-term family planning methods and more nurses should be trained on emergency contraception because they are few who know”. (IDI, healthcare provider)
In particular, providers working in outpatient health centers, dispensaries and faith-based facilities outside of Nairobi were unaware of the benefits of the GBVRS voucher or how one obtains the voucher if needed. The GBVRS voucher was restricted by program design to Nairobi and only a subset of facilities were contracted to provide the service.
Our findings demonstrate that the most felt benefits of the voucher program by facility managers and healthcare providers were that (i) the voucher program was a profitable business model that promotes competition and general improvement of quality of care (the processes, structures and outcomes); and (ii) the vouchers program plays a positive role in reducing inequity and improving access to maternal, newborn and other reproductive health services.
Voucher program as a profitable business model
Across the different study sites, facility managers reported a primary benefit of the program to be the reliable source of revenue it provided. Managers at private and mission facilities reported the source of income as the biggest benefit from the program. Although facility managers in the public sector reported the income from the program as a benefit, majority of the health facility managers expressed disappointment with being unable to use the funds to improve their services due to restrictive guidelines on use of the finances from the MOH. A facility manager had this to say;
“The advantage to the facility is, one; they are getting another source of funds which is coming to boost the facility’s upkeep and standards. Once that money is projected to the maternity, we are able to acquire things, which we would otherwise wait for the government to deliver and it might take too long. By it being a source of funds to the facility it’s assisting the facilities.” (IDI, Public Facility manager)
“It’s a challenge because if there is that competition and we are not offering that standard given by other facilities, so there is competition for clients so we need to improve our facility even more.” (IDI, Public Healthcare provider)
Majority of health providers and managers working in private facilities felt that the extra revenue ensured availability of supplies, drugs, equipment, improving client comfort through the provision of meals, accommodation, sanitation and ensuring cleanliness and proper hygiene. In the private sector, managers reported that the investments were aimed at attracting more clients and so they concentrated more on expanding the facilities by building more wards and employing more staff. In faith based facilities, majority of the facility managers reported that they focused more on improving the clients’ comfort by increasing number of beds, improving meals, and provision of warm water. Although most health facility managers from public facilities reported inability to utilize reimbursed funds, a few public facilities were able to utilize reimbursed funds. These were mainly higher level facilities (district and county level) which were directly managed on the day to day basis by the county/district health management teams. These facilities utilized the funds on renovating existing structures and purchasing supplies such as curtains, patients’ personal effects including sanitary pads, purchase of medical equipment, supplies and drugs and improving community health education programs. The funds had also been used to improve on the job training for staff especially on reproductive health and medical complications and to conduct community-based health education at churches, chiefs’ barazas (meetings), and community groups and through the media. The quotes below demonstrate how the income earned was utilized;
“As for xxxxx, we’ve been able to paint the maternity wing, to provide hot showers, offering bath towels, basins and slippers, soap. We are also able to prepare food for our clients and to purchase a room heater for the delivery. We have also purchased a resuscitator for the babies. Staff motivation; we are able to provide lunch, training which we are able to sponsor.” (IDI, Private Healthcare provider)
“I think quality has improved in many ways because the revenue from OBA caters for general services that we give such as making sure that the right infrastructure is available, that the right services are offered in terms of quality. The revenue from the OBA has been directed towards the welfare of the clients, the welfare of the facility, the infrastructure within labor ward and even the welfare of staff. For example staffs take tea and better feeding for maternity mothers. Initially we didn’t offer tea continuously for mothers but at least now there’s tea available in labor ward and we are also preparing porridge, which is always available for the mothers.” (IDI, Public Facility manager)
Majority of health facility managers in the private sector compared to the public sector reported using the revenue to improve customer service, communication with clients, and staff friendliness to ensure client satisfaction as demonstrated by the excerpts below;
“Recently there is improvement in client-staff relationship. The staffs have tried their best to improve themselves so that they may attract many clients, the more you are good to them the more you attract them and they will bring in the voucher and you will be able even to help your hospital expand. The voucher has now helped the providers to realize need of the clients so that they don’t have to quarrel the clients, be friendly, they have to encourage them to come to the facility.” (IDI Private Facility manager)
“If you just go to the wards you will see the improvements in the facility, for example the curtains of the delivery room and ante-natal room are matching with the bed covers, something you would not expect from a government facility. The privacy has improved a lot because now you will find those beds that used to be exposed they are now partitioned with curtains to improve the privacy of the mother, whereby they are even able to stay together with the husband. Before the program there was lack of privacy” (IDI, Public Health Manager)
“I have seen facilities that just used to look like ordinary GOK (Government of Kenya) facilities but with the OBA you go there you will not believe it, you will just think you are in a private facility. And when you find the services that are offered to the mother they quality of the care. For example you find the midwife who has conducted the delivery is motivated with 500sh which goes a long way in encouraging the midwife to continue welcoming those who come for ANC promoting their facility even taking them to the labour to see and all that.” (IDI, District Public Health Nurse)
A majority of health workers at the private facilities reported that reimbursed funds were used for staff motivation in way of compensation for overtime and improvement of working conditions. For example, food and beverages were offered to healthcare staff during working hours.
“The quality is nice because they use the reimbursed funds to improve the quality of care, for example you find the midwife who has conducted the delivery is motivated with 500ksh given to her by the facility which goes a long way in encouraging the midwife to continue to welcome those who come for antenatal clinics thus promoting their facility even taking them to the labor to see and all that.” (IDI, District Public Health Nurse)
“With the facilities offering the OBA program…, rarely do I get frustrated when I conduct a delivery and then I’m threatened by the boss that “you have conducted that delivery, who will pay for it?” Nowadays we don’t have that; we know the voucher will cater for it. But there before we used to get that threat.” (IDI, Healthcare provider)
Reducing inequity and improving access to maternal and newborn services
Providers from private facilities reported increased number of client’s, especially poor women who would otherwise not afford to seek their services. Overall, majority of health providers and managers felt that the voucher program had increased access to and use of reproductive health services, especially skilled birth delivery, among the poor. Most providers cited improved of children as an unintended contribution of the program due to reduced health financing burden.
“The majority of the people in the community are poor, and if they are able to access these vouchers, it is helping them because they could not have had access to a health facility like here because of money issues, but now they are able to get services because of these vouchers.” (IDI, healthcare provider)
“Because we are able now to capture all mothers especially the poor mothers who never come to facilities. If a mother has come for ANC we give them the health talk, we encourage them, and there are those mothers who get precipitate labor maybe at night they deliver at home, not intentionally. So they are able to come the following day for their check up and the checkup of the baby and also family planning.” (IDI Facility manager)
“We are seeing the family planning uptake is also high because once you follow the client well in the antenatal period they come even post-delivery. They are able to follow up their clinics [appointments] well.” (IDI, Healthcare provider)
“I think with the coming of the OBA, the number of clients who are seeking especially deliveries in hospitals has increased and there is an increase in the reimbursement, whatever they pay. We are also able to improve our services, like we are able to buy new bed sheets, new beds; new delivery beds and we are able to make the wards a bit more comfortable. We have put tiles in the wards and put curtains so that they feel comfortable.” (IDI, Healthcare provider)
“Some babies who used to miss the first vaccinations which are very vital and now they normally get them. Like now the babies who are being born are protected from the word go. Before the Voucher program you could get a baby at six weeks without a BCG, but currently you can’t get unless somebody is very ignorant. Mortality rate in the community has gone down if I may say so and diseases which normally get children who are not protected; like now mostly our children are protected from TB.” (IDI, Healthcare provider
Facility managers and providers’ perceived challenges with the voucher program
Facility managers and providers identified the key challenges they experienced with the voucher program to be mainly: (i) the working relations of the health facilities and the VMA including some aspects of the program functioning designs (ii) effect of vouchers on the workload (iii) existing challenges with the public health systems
Complex reimbursement and claims process
Although most managers interviewed reported ease in preparing the required reports by the voucher management agent (VMA), those in the rural areas reported dissatisfaction with the fact that they had to deliver the reports monthly to the VMA field managers who were based in towns. Health workers in the rural areas described their facilities as being understaffed, therefore, sending one of the staff to deliver the report created a problem of further less providers in the facility. They also felt that lack of accessible roads created problems in delivering the reports. Some providers cited lack of vehicles or transport. The majority of health facility managers observed that delay in reimbursement was a great challenge. Such managers felt that electronic reporting should be adopted by the VMA, and that overall communication and provision of feedback to the facilities needed improvement by the VMA. In addition, use of standard operating procedures on claims and reimbursement could improve communications between providers and VMA. Further such rural facilities’ managers felt that the VMA failed to provide prompt feedback for claims against services offered and sometimes there was no feedback on claims that were declined. Such providers and facility managers felt the nature of the relationship with the VMA was poor. However, health facility managers and providers in most urban areas felt that the relationship and support provided by the VMA was adequate and most managers were satisfied with the reimbursement process. The excerpt below demonstrates the support that health workers expressed.
“We need to have some of the computer machines that will facilitate us prepare and send the required reports”. (IDI, Healthcare provider)
“We can benefit more from the training together with my fellow colleague so provide training for those who were not trained. I think just about the procedure that should be followed so that at the end of the day we can be reimbursed without any question”. (IDI, Healthcare provider).
Effect of vouchers on the workload
Facility managers and providers in public and private facilities reported different effects of the voucher program on workload (in terms of increasing patient flow). Majority of facility managers and providers in public facilities reported that the voucher increased their workload, in light of the fact that the government had not deployed new staff to cater for increased utilization. Most providers in public facilities reported that with increased workload they felt overwhelmed. However for public facilities that lacked structures that facilitated continuous improvement of quality of services offered, the client load reduced due to increased competition from accredited facilities.
“Competition from the private [sector] is affecting other facilities for example because we have the GOK (Government of Kenya) facilities that are not accredited so [at] those ones the deliveries come down. We find ourselves explaining to the provincial managers who expects us to do better than that but of course we tell them that when the OBA came in the mother will always choose the best place to deliver in. And most of the time it happens to be the private facilities”. (IDI, Facility manager)
“Like now you see I’m alone. Today I had to conduct a delivery and I have a queue here. The delivery I’m conducting is for a voucher user and the antenatal mothers who are seated here are also voucher users. So I either had to delay the delivery, which cannot be delayed but the mothers seated here had to delay. So lack of staff is affecting us”. (IDI, Healthcare provider)
Existing challenges with the public health systems
Most managers from dispensaries and health centers in the public facilities had the view that that the referral mechanism needed to be improved. They describe the situation as difficult due to the lack of ambulances or taxis, especially in the remote areas and when available they took time to provide services or the ambulances had mechanical problems.
“I think most of the challenges are in referral, we may call the ambulance and they say they are sending the ambulance, and you know from xxxx to here is xxx Kilometers. The roads are terribly bad, there before when the roads were better they could take 45 min… [if there is] fetal distress or this mother is bleeding or there is a cord prolapse, you know that one now, it worsens the whole thing”. (IDI, Health Facility Manager,)
In public facilities some providers and managers reported that at times they were unable to offer services due to lack of drugs, supplies and equipment and the problem of understaffing. Some managers in the public health facilities observed that voucher clients complained of lack of privacy and sharing of beds.
“There is overcrowding especially if the space is not big and if it is not possible to expand. Because like now you find clients are sleeping two because they have only one postnatal room. So when they deliver and they are many together with the others we don’t have separate beds to keep them so you make them just share. So she may feel she has not been given the best because she has a voucher”. (IDI, Healthcare provider,)
Some public facilities managers felt that they were not able to improve many aspects of the services offered because of the inability to utilize reimbursed funds.
“Initially we didn’t have a problem but from March this year there was this circular from the Ministry of Health that we should have one joint account so we are not able to access the money direct. So we are taking too long to get the money so we are not able to cater for our clients the way we are supposed to because of these government bureaucracies and yet there is a lot of competition from other facilities”. (IDI, Facility Head Nurse)