Increasing Access to Institutional Deliveries Using Demand and Supply Side Incentives


Published on

This presentation was given by Elizabeth Ekirapa-Kiracho of Makerere University School of Public health to XII Ascon, Dhaka, February 2009. The author is a member of the Future Health Systems Research Programme Consortium (

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Increasing Access to Institutional Deliveries Using Demand and Supply Side Incentives

    1. 1. 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
    2. 2. Outline of the presentation <ul><li>Introduction </li></ul><ul><li>Access to maternal health services in Uganda </li></ul><ul><li>Increasing access to services for the poor </li></ul><ul><li>The Intervention </li></ul><ul><li>Focus on the poor </li></ul>
    3. 3. Introduction <ul><li>The poor more predisposed to ill health </li></ul><ul><li>The poor have reduced access to preventive and curative interventions </li></ul><ul><li>Gaps in maternal mortality between rich and poor </li></ul>
    4. 4. Increasing access to services for the poor <ul><li>New innovations in financing hold promise for improving access to the poor </li></ul><ul><li>CBHI/Subsidized health insurance </li></ul><ul><li>Conditional cash transfers </li></ul><ul><li>Equity funds </li></ul><ul><li>Vouchers </li></ul><ul><li>Provider subsidies </li></ul>[Gwatkin et al (2004),Jacobs et al (2005),Lagarde et al (2007),Peters et al (2007)]
    5. 5. Interventions that increase access <ul><li>Systematic & intensive approaches to delivering effective health care </li></ul><ul><li>Improvement in access </li></ul><ul><li>Prompts to encourage utilization </li></ul><ul><li>Combination of approaches </li></ul><ul><li>Multidisciplinary approaches </li></ul><ul><li>Expressed/ identified needs </li></ul><ul><li>Involve peers </li></ul>[Arblaster et al ( 1996), Victoria et al ( 2007) ]
    6. 6. Why maternal health services? <ul><li>Maternal mortality has been almost stagnant for the past 2 decades </li></ul><ul><li>Maternal mortality ratio 435 per 100,000 </li></ul><ul><li>Fifth MDG – reduce by 75% </li></ul><ul><li>Over 80% of maternal deaths are due to five direct causes, each of which require facility-based care </li></ul>.
    7. 7. Why maternal health services? <ul><li>Low delivery in health facilities </li></ul><ul><li>38% in 1995 and 42% in 2006 </li></ul><ul><li>Inequities in access to delivery care </li></ul><ul><li>79% urban areas & 36 % rural </li></ul><ul><li>75% highest quintile 27% lowest quintile </li></ul><ul><li>Most interventions – Supply side </li></ul>.
    8. 8. The intervention <ul><li>? </li></ul>
    9. 9. Demand and supply side initiatives <ul><li>Demand side - Performance based funding approach </li></ul><ul><li>Patients decide where to seek services, this determines the amount of reimbursement </li></ul><ul><li>Supply side </li></ul><ul><li>Health system strengthening </li></ul>
    10. 10. Aim <ul><li>To increase institutional delivery and by so doing contribute in reducing maternal mortality (MDG 5) in Uganda and the regional countries </li></ul><ul><li>Promote the implementation of evidence based strategies </li></ul>
    11. 11. Objectives <ul><li>Identify the demand side factors that influence delivery at health facilities </li></ul><ul><li>Identify the appropriate pathways through which vouchers influence delivery care services at public, PNFP and PFP health facilities </li></ul>
    12. 12. Specific Objectives <ul><li>Assess the effectiveness of a voucher system in increasing deliveries at public, PNFP and PFP health facilities </li></ul><ul><li>Assess the effectiveness of a voucher system in increasing deliveries among the poor at public, PNFP and PFP health facilities </li></ul><ul><li>Estimate the incremental cost of implementing a voucher system for increasing deliveries at health facilities </li></ul>
    13. 13. Methodology <ul><li>Cluster randomized trial </li></ul><ul><li>4 sub-districts (2 intervention and 2 control) </li></ul><ul><li>Intervention: Voucher for transport and maternity services </li></ul>
    14. 14. Methodology <ul><li>Primary outcome: % change in the proportion of women delivering in health facilities in the intervention and control areas </li></ul><ul><li>Secondary outcomes </li></ul><ul><li>Birth outcomes </li></ul><ul><li>Number of ANC visits </li></ul><ul><li>Number of post natal visits </li></ul>
    15. 15. Methodology <ul><li>Analytical method: Difference in differences analysis </li></ul><ul><li>The difference of differences of the results from the intervention and control sites </li></ul><ul><li>Obtained from baseline and end line surveys </li></ul>
    16. 16. Main activities during the intervention <ul><li>Stakeholder Consultation </li></ul><ul><li>Needs assessment </li></ul><ul><li>Baseline survey </li></ul><ul><li>Training </li></ul><ul><li>Piloting of the intervention </li></ul><ul><li>Implementation </li></ul><ul><li>Endline survey </li></ul><ul><li>Dissemination </li></ul>
    17. 17. Barriers to the poor using services <ul><li>Cost </li></ul><ul><li>Long distances and lack of transport </li></ul><ul><li>Attitudes of health workers and other quality related issues </li></ul><ul><li>Informal payments </li></ul><ul><li>Preference for traditional birth positions/ attendants </li></ul>[ Amooti et al (1997); Atuyambe et al (2005;) Kyomuhendo et al (2003); Munaaba (1995);Waiswa ( 2008) ]
    18. 18. Focus on the poor - Implementation in rural areas
    19. 19. Allow choice -Public and private <ul><li>Choice </li></ul><ul><li>Choice </li></ul>
    20. 20. Increase awareness <ul><li>Sensitization within the community to inform them about the intervention </li></ul>
    21. 21. Performance based method of payment <ul><li>Address quality issues </li></ul><ul><li>Informal payments </li></ul><ul><li>Incentives </li></ul>
    22. 22. Removal of transport and cost barriers
    23. 23. Locally available transport
    24. 24. Accessing services – Multiple problems
    25. 25. Increasing access to institutional delivery
    26. 26. Acknowledgements <ul><li>DFID </li></ul><ul><li>FHS Partner Institutions </li></ul><ul><li>Researchers </li></ul>
    27. 27. Referances <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Atuyambe, L., F. Mirembe, et al. (2005). &quot;Experiences of pregnant adolescents - voices from Wakiso district, Uganda.&quot; Afr Health Sci 5(4): 304-9. </li></ul><ul><li>Gwatkin, D. R., A. Bhuiya, et al. (2004). &quot;Making health systems more equitable.&quot; Lancet 364(9441): 1273-80. </li></ul><ul><li>Jacobs, B. and N. Price (2005). &quot;Improving access for the poorest to public sector health services: insights from Kirivong Operational Health District in Cambodia.&quot; Health Policy and Planning 21(1): 27-39. </li></ul>
    28. 28. Referances <ul><li>Kyomuhendo, G. B. (2003). &quot;Low use of rural maternity services in Uganda: impact of women's status, traditional beliefs and limited resources.&quot; Reprod Health Matters 11(21): 16-26. </li></ul><ul><li>Lagarde, M., A. Haines, et al. (2007). &quot;Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review.&quot; JAMA 298(16): 1900-10. </li></ul><ul><li>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. </li></ul><ul><li>Peters, D. H., A. Gary, et al. (2007). &quot;Poverty and Access to Health Care in Developing Countries.&quot; Ann N Y Acad Sci. 2007 Oct 22 [Epub ahead of print] . </li></ul><ul><li>UBoS (2007). Uganda demographic and health survey, 2006. Calverton, Maryland, USA. </li></ul><ul><li>Victoria et al .JAMA. 2007 Oct 24;298(16):1900-10. </li></ul><ul><li>Waiswa, P., M. Kemigisa, et al. (2008). &quot;Acceptability of evidence-based neonatal care practices in rural Uganda - implications for programming.&quot; BMC Pregnancy Childbirth 8: 21. </li></ul><ul><li>  </li></ul>
    29. 29. <ul><li>Thank you for listening Good ending slide </li></ul>[Thank you for listening]