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Impact of voucher system on access to maternal and child health services in Eastern Uganda


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John Bua of Makerere University presents on a voucher scheme in Eastern Uganda to transport pregnant women to the care facility at iHEA 2011 in Toronto, Canada.

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Impact of voucher system on access to maternal and child health services in Eastern Uganda

  1. 1. Making Health Systems Work for the Poor Impact of voucher system on access to MCH services in Eastern Uganda Makerere University School of Public health John Hopkins University FHS Uganda
  2. 2. Acknowledgements <ul><li>DFID </li></ul><ul><li>Melinda & Gates Foundation </li></ul><ul><li>District officials </li></ul><ul><li>FHS Partner Institutions ( JHU, IDS, ICDDRB, CHEI, UIN,IHMR) </li></ul><ul><li>Researchers </li></ul>
  3. 4. Introduction <ul><li>Access to MCH services has been constrained by geographical, transport and financial barriers. </li></ul><ul><li>Most interventions are directed to the supply side. </li></ul><ul><li>Despite interventions of building more health units, equipping them and staffing them (HSSP 2010/11-2014/15). </li></ul>
  4. 5. Introduction- continued <ul><li>Utilization of MCH services has been low - Health facility deliveries (42%) (UDHS 2006) 4 th ANC (47%) and PNC within 1 st 2 days (23%) </li></ul><ul><li>Thus a need to have mix of both demand and supply side interventions to increase access to MCH services and contribute to the achievement of MDGs 4 & 5. </li></ul>
  5. 6. Objectives <ul><li>To use the voucher system increase access to MCH services </li></ul><ul><li>To generate evidence that can inform designing, implementing and scale up of similar innovations. </li></ul>
  6. 7. Methodology <ul><li>Non randomized trial </li></ul><ul><li>4 districts ( Kamuli, Buyende, Pallisa and Kibuku) </li></ul><ul><li>2 intervention and 2 control </li></ul><ul><li>Intervention: Voucher for transport and maternity child health services </li></ul>
  7. 8. Intervention Vouchers for transport Vouchers for MCH services Maternal child health services Pregnant women in control Maternal child health services Training Supervision Supplies, drugs and equipment Pregnant women in Intervention
  8. 9. Cost of service vouchers 0.32 0.46 PNC 24.95 49.9 C/section 2.30 3.07 DELIVERY 0.32 0.46 ANC 1,2,3&4 Implementation phase 1 st Cost Price 0.86 1.15 PNC 43.19 57.58 C/section 4.32 5.76 DELIVERY 0.86 1.15 ANC 2,3&4 0.72 0.96 ANC 1 Pilot Phase Cost Price Public ($) Private ($)
  9. 10. Methods- continued <ul><li>Data collection methods </li></ul><ul><ul><li>Quantitative methods </li></ul></ul><ul><ul><ul><ul><li>Health facility records </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Health worker surveys </li></ul></ul></ul></ul><ul><ul><li>Qualitative methods </li></ul></ul><ul><ul><ul><ul><li>Focus group discussions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Key informant interviews </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Community in-depth interviews </li></ul></ul></ul></ul>
  10. 11. Results
  11. 12. Results
  12. 13. Results
  13. 14. Results
  14. 15. Results <ul><li>Increased utilisation of facility deliveries </li></ul><ul><li>Increased motivation of health workers </li></ul><ul><ul><li>Improved working conditions </li></ul></ul><ul><ul><li>Readily available at health units </li></ul></ul><ul><ul><li>Monetary incentives </li></ul></ul><ul><li>Improved supply of drugs and supplies </li></ul>
  15. 16. Results <ul><li>Formal & Informal costs of treatment reduced </li></ul><ul><li>Improved perceived quality of care </li></ul><ul><li>Improved geographical access </li></ul><ul><li>Change in health seeking behaviour </li></ul><ul><li>Created agents for MCH </li></ul>
  16. 17. Results <ul><li>Increased community awareness about benefits of facility deliveries </li></ul><ul><li>Increased support from the community leaders </li></ul><ul><li>Income generating activity for the community </li></ul><ul><li>Increased demand for health workers to provide MCH services </li></ul>
  17. 18. Challenges <ul><li>Inadequate resources-staffing and supplies </li></ul><ul><li>Appropriate referral transport </li></ul><ul><li>Record keeping </li></ul><ul><li>Timely payments for health units and transporters </li></ul><ul><li>Rising fuel costs </li></ul><ul><li>Sustainability </li></ul>
  18. 19. Lessons learned <ul><li>The demand for MCH services has been there but has been mired by lack of affordable transport and cost of health services. </li></ul><ul><li>Using locally available resources like local transport providers and subsidized health service costs can improve access to health services. </li></ul>
  19. 20. Lessons learned <ul><li>Such ventures avail resources to health facilities and promote formulation of innovation mechanisms on how to improve MCH service delivery </li></ul><ul><li>But community response in terms of uptake of health services in such ventures may overwhelm the available financial and human resources. </li></ul>
  20. 21. Conclusion <ul><li>Vouchers for MCH and use of available resources within the community can help overcome geographical and financial barriers that hinder access to MCH services. </li></ul><ul><li>However the challenge is how do we maintain a scheme that works, using available community resources without putting an extra burden to the vulnerable that need access to MCH services. </li></ul>
  21. 22. References <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>Gwatkin, D. R., A. Bhuiya, et al. (2004). &quot;Making health systems more equitable.&quot; Lancet 364(9441): 1273-80. </li></ul><ul><li>Health Sector Strategic Plan III 2010/11-2014/15 (Uganda) </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>
  22. 23. References <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>  </li></ul>
  23. 24. <ul><li>Thank you for listening Good ending slide </li></ul>[Thank you for listening]