1. SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with Banyan Global Jhpiego Marie Stopes International Monitor Group OHanlon Health Consulting Study of Changamkas Maternity Savings Card: Preliminary Evaluation Results Second Global Symposium on Health Systems Research November 1, 2012

2. Overview Financial barriers limit use of maternity health services in developing countries. Changamka card, which provides convenience as well as savings mechanism, is promising. Test of card at Pumwani Hospital in 2010-2011. Convenience feature of card proved to be more important to the Pumwani clientele. Savings feature is potentially more important to other women in community. 2

3. Financial Barriers Limit Use of Maternal Health Services 90% of Kenyans not covered by health insurance, most health services bought with cash 43% of births in Kenya occur in health facilities, a significant barrier to reducing MMR Few Kenyans have bank accounts, but many use M-Pesa mobile phone system for savings M-Pesa cannot be used at health facilities, has no commitment savings mechanism 3

4. The Promise of a Maternal Services Card Simple stored-value smart card (or e-card) For users: Convenient, safe and cost-free, allows for dedicated savings For health facilities: Low cost, attractive to customers, reduces nonpayment risk Maternity services have predictable timeline and cost, are well suited to a savings mechanism. 4

5. Changamka Convenience/Savings Card Changamka MicroHealth Limited, established in 2008 in Nairobi Offers healthcare savings cards, including the maternity care savings card 5 Facilitates cashless transactions Provides a micro-savings mechanism

6. Trial of Card at Pumwani Hospital Card offered at kiosk in Pumwani Hospital from July 2010 to September 2011. Deposits at kiosk and through mobile phones (M-Pesa). Card use fees borne by the hospital. Card can currently be used at 9 private hospitals in Nairobi and in hospitals in Mombasa and Naivasha. 6

7. Trial of Card at Pumwani Hospital Pumwani Maternity Hospital owned by Nairobi City Council. Largest maternity hospital in Sub-Saharan Africa, with about 27,000 deliveries per year. Provides CEOC. Pumwani Hospital clientele is large, distinctive. 7

8. Trial of Card at Pumwani Hospital 1 st -time mother services (VDLR, HB count, blood profile, urinalysis) $6.00 Normal delivery: $36.00 + $4.85/night (1) or C-Section: $72.00+ $4.85/night (3) Follow-up ANCs: $0.60 Registration & 1 st ANC: $3.00 PNCs: $0.60 8

9. Assessment of the Card Trial Natural experiment at Pumwani Hospital, not a rigorous, controlled evaluation Changamka data on user transactions Survey data Changamka card users Pumwani Hospital clients from same neighborhoods who did not get Changamka cards Community sample: Women from same neighborhoods who gave birth in period covered by the study In-depth interviews with subsample of survey respondents 9

10. Card Safety and Convenience Findings Card users versus comparison group (women who went to Pumwani Hospital for services before or after 15 months when card was offered): Average card user made 4.3 ANC visits, 14% more than comparison group (difference statistically significant across education and income subgroups). Card users were more likely to have at least 4 ANC visits (the WHO recommendation). Convenience and security appear to drive this result more than savings feature. 10

11. Card Safety and Convenience Findings Card user sample: 78% found card convenient to use, 60% said card helped pay for services, leave hospital more easily. 80% said the card safer than carrying cash, 87% thought it was more convenient than M-Pesa. Community sample: 71% do not feel safe carrying money to a hospital. 11

12. Card Saving Findings 6% of card users engaged in genuine savings and two-thirds of savers used cards for deliveries. Card users versus comparison group: No difference in deliveries at facilities (96% for both groups). No difference in use of skilled birth attendants. Predictable finding, because most Pumwani Hospital clients committed to facility delivery, many covered by insurance. 12

13. Card Saving Findings Card user sample: 75% said card helped them save money by not letting them spend it on other things. 15% said card helped by preventing their families from spending the money on other things. Community sample: 60% were interested in using a maternity card for saving if it could be used at multiple facilities. Interest grew to 87% if delivery cost held to KSh 3,000. 13

14. Card Users Have More Education and Income than Community Sample 14

15. SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with Banyan Global Jhpiego Marie Stopes International Monitor Group OHanlon Health Consulting David_Long@abtassoc.com Thierry_van_Bastelaer@abtassoc.com Benjamin_Woodman@abtassoc.com www.shopsproject.org Thank You