Increase in facility-based deliveries associated with a maternal health voucher programme in informal settlements in Nairobi, Kenya

Health Policy Plan. 2013 Mar;28(2):134-42. doi: 10.1093/heapol/czs030. Epub 2012 Mar 21.


Objective: To measure whether there was an association between the introduction of an output-based voucher programme and the odds of a facility-based delivery in two Nairobi informal settlements.

Data sources: Nairobi Urban Health and Demographic Surveillance System (NUHDSS) and two cross-sectional household surveys in Korogocho and Viwandani informal settlements in 2004-05 and 2006-08.

Methods: Odds of facility-based delivery were estimated before and after introduction of an output-based voucher. Supporting NUHDSS data were used to determine whether any trend in maternal health care was coincident with immunizations, a non-voucher outpatient service. As part of NUHDSS, households in Korogocho and Viwandani reported place of delivery and the presence of a skilled birth attendant (2003-10) and vaccination coverage (2003-09). A detailed maternal and child health (MCH) tool was added to NUHDSS (September 2006-10). Prospective enrolment in NUHDSS-MCH was conditional on having a newborn after September 2006. In addition to recording mother's place of delivery, NUHDSS-MCH recorded the use of the voucher.

Findings: There were significantly greater odds of a facility-based delivery among respondents during the voucher programme compared with similar respondents prior to voucher launch. Testing whether unrelated outpatient care also increased, a falsification exercise found no significant increase in immunizations for children 12-23 months of age in the same period. Although the proportion completing any antenatal care (ANC) visit remained above 95% of all reported pregnancies and there was a significant increase in facility-based deliveries, the proportion of women completing 4+ ANC visits was significantly lower during the voucher programme.

Conclusions: A positive association was observed between vouchers and facility-based deliveries in Nairobi. Although there is a need for higher quality evidence and validation in future studies, this statistically significant and policy relevant finding suggests that increases in facility-based deliveries can be achieved through output-based finance models that target subsidies to underserved populations.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Child
  • Cross-Sectional Studies
  • Delivery, Obstetric / economics
  • Delivery, Obstetric / statistics & numerical data*
  • Female
  • Financing, Government* / organization & administration
  • Humans
  • Kenya / epidemiology
  • Maternal Health Services / economics
  • Maternal Health Services / organization & administration
  • Maternal Health Services / statistics & numerical data*
  • Middle Aged
  • Parity
  • Pregnancy
  • Socioeconomic Factors
  • Young Adult