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Study Overview

Evaluation of The Impact of Removal of User Fees For Maternal Health Services on Universal Health Coverage in Kenya
Study is 3ie funded:
Study ID:
Initial Registration Date:
Last Update Date:
Study Status:
In Development

The Kenyan government has made efforts to provide health services free of charge. Studies show that user fee removals result in short-term utilization gains for health service but these erode over time, particularly if no alternative funding replaces the revenue. This study will assess the impact of changes in policy on user fees on the use of maternity services in Kenya from 1995 to 2014 in Kenya. The study will take into account the impact of other alternative financing strategies like vouchers and results-based finance, and subsidized health insurance for public and private sector initiatives. The study will use cross-sectional and time-series designs to study the environment of user fee removals in Kenya. Specific activities include: (1) analysis of existing Kenya Demographic and Health Surveys datasets for 1998, 2003, 2008-2009, and 2014; (2) analysis of existing health management information systems datasets; (3) quantitative interviews with 2,176 women aged 18 years and above in seven rural counties of Kenya (4) in-depth interviews with key informants; (5) focus group discussions with women who gave birth immediately before and after the introduction of free maternity servic

Registration Citation:

Abuya, T. and Bellows, B., 2016. Evaluation of The Impact of Removal of User Fees For Maternal Health Services on Universal Health Coverage in Kenya. Registry for International Development for Impact Evaluations (RIDIE). Available at: 10.23846/ridie085

Health, Nutrition, and Population
Additional Keywords:
Health Care Financing, Kenya, User fees, Maternal Health
Secondary ID Number(s):
P222/2016- Protocol Approved by AMREF-AFRICA Ethics and Scientific Research Committee

Principal Investigator(s)

Name of First PI:
Timothy Abuya
Population Council
Name of Second PI:
Ben Bellows
Population Council

Study Sponsor

Study Sponsor Location:
United States

Research Partner

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Intervention Overview


Kenya has a history of changes in fee policies in health facilities. They include free service use between 1965-1988; suspension of user fees in 1990; reintroduction of user fee in phases in 1991; The “10/20 policy” for maternal health services in public facilities, which established a fee of 10 shillings at dispensary and 20 shillings at health centers in 2004 without replacement funding. In 2007, the 10/20 policy was removed and a policy of no user fees was declared for all facilities with no alternative source of funding. In 2008, the government tested innovative strategies to increase access to services and improve financing for facilities where user fees had been removed. In 2013, the new government announced that maternity and primary care would be free in public facilities. This study will examine the effects of these policy changes on utilization of maternal services and whether the combination of subsidies coupled with user fee removal, would produce a sustained increase in demand for maternal healthcare. The target beneficiaries are women and children.

Theory of Change:
Multiple Treatment Arms Evaluated?

Implementing Agency

Name of Organization:
Ministry of Health
Type of Organization:
Public Sector, e.g. Government Agency or Ministry

Program Funder

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Intervention Timing

Intervention or Program Started at time of Registration?
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Evaluation Method

Evaluation Method Overview

Primary (or First) Evaluation Method:
Difference in difference/fixed effects
Other (not Listed) Method:
Additional Evaluation Method (If Any):
Other (specify)
Other (not Listed) Method:
Secondary analysis using interrupted time series

Method Details

Details of Evaluation Approach:

The study will have three components. Component one will analyze the demographic health survey. From 1998, 2003, 2008-2009 and 2014. Component two will analyze data on births in health facilities reported through the Health management information system for the period 2010-2014. In both, interrupted time series approach will be used to examine changes in trends of facility-based births over time. The interruptions are pre and post -2004 policy changes. The final component will involve collection of primary data from 2,156 women aged 18-49 years from the reproductive health vouchers sites to examine the effect of user fee removals in 2013. This will be compared with data collected from a quasi-experimental design in 2012 on voucher sites and non-voucher sites. The analyses will entail difference-in-differences estimation using data of 2012 and 2016 to determine the net contribution of the user fee removal plus vouchers above any improvement in maternal healthcare uptake (facility-based deliveries) attributable to user fee removal alone. A policy analysis component through document review, focus group discussion and key informant interviews will be used to provide context.

Outcomes (Endpoints):

Intermediate outcomes: Primary outcome -increased volume of facility birth deliveries; inclusion of low income populations that newly afford the service. Secondary outcome improved quality of services. Final outcomes: stabilized or decreased volume of facility deliveries; Secondary -Unchanged quality of services

Unit of Analysis:
Facility births /counties

A combination of user fee removals and voucher subsidy has no effect on facility births before and after 2013 user fee removals

Unit of Intervention or Assignment:
Number of Clusters in Sample:
294 clusters
Number of Individuals in Sample:
Component 1: 34,621 births to women aged 15-49 years, component 3- 2,156 women aged 18-49 years
Size of Treatment, Control, or Comparison Subsamples:
Treatment will have 1232 observations and 924 from the comparison sites

Supplementary Files

Analysis Plan:
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Outcomes Data

Data for component one will be sourced from demographic health survey for 1998, 2003, 2008-2009 and 2014. This data is publicly available. Data for component two will be accessed from the Health management information system for the period 2010-2014. Household survey data for component three will be collected in 2016. Data for the policy analysis component will be sourced from document reviews, focus group discussion and key informant interviews.
Data Already Collected?
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Treatment Assignment Data

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Data Analysis

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Study Materials

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Registration Category

Registration Category:
Prospective, Category 1: Data for measuring impacts have not been collected

Completion Overview

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Preliminary Report:
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Data Availability

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Other Materials

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Description of Changes:

Study Stopped