Pragmatic pluralism for health: Understanding the role of public financing and public-private engagement on use, quality, and equity in access to maternal health services in Kenya

This thesis assesses the effects of having pluralistic systems of health financing and service provision on universal healthcare coverage with a case study on maternal health in Kenya. Through five research papers using a mix of systematic literature review, qualitative, and quasi-experimental quantitative methods, this thesis answers three primary research questions. First, how do researchers measure the contribution of the private sector to maternal health and family planning service provision and how much care does the private sector provide in sub-Saharan Africa (SSA)? Second, how did Kenya’s pluralistic financing policies and public-private engagement strategies for health arise and evolve over time? Finally, what are the impacts of user fee removals and subsidized vouchers on use, sector, quality, continuity, and equity of maternal care in Kenya? The findings from the systematic review suggest that there is substantial heterogeneity in the way that the private health sector is defined in scientific literature, making it difficult to compare estimates of private sector health provision. The qualitative study reveals that Kenya’s pluralistic health system results from the confluence of many historical, social, political, and economic factors and effective lobbying by the private for-profit sector. Finally, the three quasi-experimental studies highlight a complex set of outcomes resulting from user fee removal policies and the safe motherhood voucher program in Kenya. The 10/20 policy was associated with positive effects on the timing and number of ANC visits; however, these improvements were unrelated to use of the public primary care facilities that the policy targeted. The voucher program increased use of facility-based delivery care among poor women; however, it had no impact on use of four or more ANC visits or postnatal care. After the free maternity services policy was introduced, the voucher program no longer improved use of facility-based delivery among the poor; however, use of the private sector remained much higher in voucher counties. Both the voucher program and insurance coverage had positive impacts on continuity of maternal care for poor women, while introduction of the free maternity services policy did not. Many factors affect women’s use of maternal health services beyond the cost of care. Making services free in the public sector is not sufficient to eliminate disparities in access to health services; policymakers must therefore simultaneously address both financial and nonfinancial barriers to service use. Health financing strategies involving private providers have the potential to equitably increase service use and continuity, provided that the cost of care is subsidized for users with the lowest ability to pay.