Making Health Systems Work for the Poor Increasing Access to Institutional Deliveries Using Demand and Supply Side Incentives Elizabeth Ekirapa-Kiracho Makerere University School of Public health Research Coordinator, FHS Uganda XII Ascon, Dhaka

Outline of the presentation Introduction Access to maternal health services in Uganda Increasing access to services for the poor The Intervention Focus on the poor

Introduction

Access to maternal health services in Uganda

Increasing access to services for the poor

The Intervention

Focus on the poor

Introduction The poor more predisposed to ill health The poor have reduced access to preventive and curative interventions Gaps in maternal mortality between rich and poor

The poor more predisposed to ill health

The poor have reduced access to preventive and curative interventions

Gaps in maternal mortality between rich and poor

Increasing access to services for the poor New innovations in financing hold promise for improving access to the poor CBHI/Subsidized health insurance Conditional cash transfers Equity funds Vouchers Provider subsidies [Gwatkin et al (2004),Jacobs et al (2005),Lagarde et al (2007),Peters et al (2007)]

New innovations in financing hold promise for improving access to the poor

CBHI/Subsidized health insurance

Conditional cash transfers

Equity funds

Vouchers

Provider subsidies

Interventions that increase access Systematic & intensive approaches to delivering effective health care Improvement in access Prompts to encourage utilization Combination of approaches Multidisciplinary approaches Expressed/ identified needs Involve peers [Arblaster et al ( 1996), Victoria et al ( 2007) ]

Systematic & intensive approaches to delivering effective health care

Improvement in access

Prompts to encourage utilization

Combination of approaches

Multidisciplinary approaches

Expressed/ identified needs

Involve peers

Why maternal health services? Maternal mortality has been almost stagnant for the past 2 decades Maternal mortality ratio 435 per 100,000 Fifth MDG – reduce by 75% Over 80% of maternal deaths are due to five direct causes, each of which require facility-based care .

Maternal mortality has been almost stagnant for the past 2 decades

Maternal mortality ratio 435 per 100,000

Fifth MDG – reduce by 75%

Over 80% of maternal deaths are due to five direct causes, each of which require facility-based care

Why maternal health services? Low delivery in health facilities 38% in 1995 and 42% in 2006 Inequities in access to delivery care 79% urban areas & 36 % rural 75% highest quintile 27% lowest quintile Most interventions – Supply side .

Low delivery in health facilities

38% in 1995 and 42% in 2006

Inequities in access to delivery care

79% urban areas & 36 % rural

75% highest quintile 27% lowest quintile

Most interventions – Supply side

The intervention ?

?

Demand and supply side initiatives Demand side - Performance based funding approach Patients decide where to seek services, this determines the amount of reimbursement Supply side Health system strengthening

Demand side - Performance based funding approach

Patients decide where to seek services, this determines the amount of reimbursement

Supply side

Health system strengthening

Aim To increase institutional delivery and by so doing contribute in reducing maternal mortality (MDG 5) in Uganda and the regional countries Promote the implementation of evidence based strategies

To increase institutional delivery and by so doing contribute in reducing maternal mortality (MDG 5) in Uganda and the regional countries

Promote the implementation of evidence based strategies

Objectives Identify the demand side factors that influence delivery at health facilities Identify the appropriate pathways through which vouchers influence delivery care services at public, PNFP and PFP health facilities

Identify the demand side factors that influence delivery at health facilities

Identify the appropriate pathways through which vouchers influence delivery care services at public, PNFP and PFP health facilities

Specific Objectives Assess the effectiveness of a voucher system in increasing deliveries at public, PNFP and PFP health facilities Assess the effectiveness of a voucher system in increasing deliveries among the poor at public, PNFP and PFP health facilities Estimate the incremental cost of implementing a voucher system for increasing deliveries at health facilities

Assess the effectiveness of a voucher system in increasing deliveries at public, PNFP and PFP health facilities

Assess the effectiveness of a voucher system in increasing deliveries among the poor at public, PNFP and PFP health facilities

Estimate the incremental cost of implementing a voucher system for increasing deliveries at health facilities

Methodology Cluster randomized trial 4 sub-districts (2 intervention and 2 control) Intervention: Voucher for transport and maternity services

Cluster randomized trial

4 sub-districts (2 intervention and 2 control)

Intervention: Voucher for transport and maternity services

Methodology Primary outcome: % change in the proportion of women delivering in health facilities in the intervention and control areas Secondary outcomes Birth outcomes Number of ANC visits Number of post natal visits

Primary outcome: % change in the proportion of women delivering in health facilities in the intervention and control areas

Secondary outcomes

Birth outcomes

Number of ANC visits

Number of post natal visits

Methodology Analytical method: Difference in differences analysis The difference of differences of the results from the intervention and control sites Obtained from baseline and end line surveys

Analytical method: Difference in differences analysis

The difference of differences of the results from the intervention and control sites

Obtained from baseline and end line surveys

Main activities during the intervention Stakeholder Consultation Needs assessment Baseline survey Training Piloting of the intervention Implementation Endline survey Dissemination

Stakeholder Consultation

Needs assessment

Baseline survey

Training

Piloting of the intervention

Implementation

Endline survey

Dissemination

Barriers to the poor using services Cost Long distances and lack of transport Attitudes of health workers and other quality related issues Informal payments Preference for traditional birth positions/ attendants [ Amooti et al (1997); Atuyambe et al (2005;) Kyomuhendo et al (2003); Munaaba (1995);Waiswa ( 2008) ]

Cost

Long distances and lack of transport

Attitudes of health workers and other quality related issues

Informal payments

Preference for traditional birth positions/ attendants

Focus on the poor - Implementation in rural areas

Allow choice -Public and private Choice Choice

Choice

Choice

Increase awareness Sensitization within the community to inform them about the intervention

Sensitization within the community to inform them about the intervention

Performance based method of payment Address quality issues Informal payments Incentives

Address quality issues

Informal payments

Incentives

Removal of transport and cost barriers

Locally available transport

Accessing services – Multiple problems

Increasing access to institutional delivery

Acknowledgements DFID FHS Partner Institutions Researchers

DFID

FHS Partner Institutions

Researchers

Referances Arblaster l, Lambert m, Entwistle V, Forster M, Fullerton D Sheldon T, Watt I. A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health. J Health Serv Res Policy . 1996 Apr;1(2):93-103. Amooti,, B. (1997). Factors influencing choice of delivery sites by pregnant mothers in Rakai district, Uganda. . Kampala, Makerere University School of Public Health. Master of Public Health. Atuyambe, L., F. Mirembe, et al. (2005). "Experiences of pregnant adolescents - voices from Wakiso district, Uganda." Afr Health Sci 5(4): 304-9. Gwatkin, D. R., A. Bhuiya, et al. (2004). "Making health systems more equitable." Lancet 364(9441): 1273-80. Jacobs, B. and N. Price (2005). "Improving access for the poorest to public sector health services: insights from Kirivong Operational Health District in Cambodia." Health Policy and Planning 21(1): 27-39.

Arblaster l, Lambert m, Entwistle V, Forster M, Fullerton D Sheldon T, Watt I. A systematic review of the effectiveness of health service interventions aimed at reducing inequalities in health. J Health Serv Res Policy . 1996 Apr;1(2):93-103.

Amooti,, B. (1997). Factors influencing choice of delivery sites by pregnant mothers in Rakai district, Uganda. . Kampala, Makerere University School of Public Health. Master of Public Health.

Atuyambe, L., F. Mirembe, et al. (2005). "Experiences of pregnant adolescents - voices from Wakiso district, Uganda." Afr Health Sci 5(4): 304-9.

Gwatkin, D. R., A. Bhuiya, et al. (2004). "Making health systems more equitable." Lancet 364(9441): 1273-80.

Jacobs, B. and N. Price (2005). "Improving access for the poorest to public sector health services: insights from Kirivong Operational Health District in Cambodia." Health Policy and Planning 21(1): 27-39.

Referances Kyomuhendo, G. B. (2003). "Low use of rural maternity services in Uganda: impact of women's status, traditional beliefs and limited resources." Reprod Health Matters 11(21): 16-26. Lagarde, M., A. Haines, et al. (2007). "Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review." JAMA 298(16): 1900-10. Munaaba (1995). Factors which influence mothers choice of location of child birth in Pallisa district, Uganda. Kampala, Makerere University School of Public Health. Masters in Public health. Peters, D. H., A. Gary, et al. (2007). "Poverty and Access to Health Care in Developing Countries." Ann N Y Acad Sci. 2007 Oct 22 [Epub ahead of print] . UBoS (2007). Uganda demographic and health survey, 2006. Calverton, Maryland, USA. Victoria et al .JAMA. 2007 Oct 24;298(16):1900-10. Waiswa, P., M. Kemigisa, et al. (2008). "Acceptability of evidence-based neonatal care practices in rural Uganda - implications for programming." BMC Pregnancy Childbirth 8: 21.

Kyomuhendo, G. B. (2003). "Low use of rural maternity services in Uganda: impact of women's status, traditional beliefs and limited resources." Reprod Health Matters 11(21): 16-26.

Lagarde, M., A. Haines, et al. (2007). "Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review." JAMA 298(16): 1900-10.

Munaaba (1995). Factors which influence mothers choice of location of child birth in Pallisa district, Uganda. Kampala, Makerere University School of Public Health. Masters in Public health.

Peters, D. H., A. Gary, et al. (2007). "Poverty and Access to Health Care in Developing Countries." Ann N Y Acad Sci. 2007 Oct 22 [Epub ahead of print] .

UBoS (2007). Uganda demographic and health survey, 2006. Calverton, Maryland, USA.

Victoria et al .JAMA. 2007 Oct 24;298(16):1900-10.

Waiswa, P., M. Kemigisa, et al. (2008). "Acceptability of evidence-based neonatal care practices in rural Uganda - implications for programming." BMC Pregnancy Childbirth 8: 21.

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