Uganda Health Vouchers Scheme: The Results So Far

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Uganda Health Vouchers Scheme: The Results So Far

  1. 1. REPRODUCTIVE HEALTH VOUCHERS IN WESTERN UGANDAImpact Evaluation<br />
  2. 2. INTRODUCTION<br /><ul><li>435 women die per 100,000 live births in Uganda.
  3. 3. Joan did not stop bleeding after giving birth, her husband left her with his mother-in-law to fetch a doctor. After 3 hours and twenty miles of biking in the dark under the pouring rain, he and the doctor reached Joan, but she had passed away.
  4. 4. That’s why we introduced the Health Voucher project: to help Mothers, like Joan, live…and we are convinced that this program can work.</li></ul>LAUNCH OF HEALTH VOUCHERS <br />
  5. 5. OVERVIEW<br /><ul><li>Review baseline survey of Uganda Reproductive Health OBA project
  6. 6. Where We Are: project’s current results, implementation gaps and challenges
  7. 7. Outline next steps for evaluation:
  8. 8. Improve the use evaluation findings
  9. 9. Thus better inform implementation</li></li></ul><li>PROJECT OBJECTIVES:Healthy Mothers and Babies<br /><ul><li>Objectives:
  10. 10. 1) To provide safe delivery packages,
  11. 11. 2) to provide non-stigmatizing treatment for STDs
  12. 12. Output:
  13. 13. Safe Delivery Packages
  14. 14. 4 ante-natal visits
  15. 15. Delivery
  16. 16. 1 post-natal visit
  17. 17. GPOBA Grant Amount:
  18. 18. US $4.3 million</li></li></ul><li>Reproductive Health Vouchers in Uganda(OBA project) <br />Targeting: Geographic (20 districts) and self-selection: all sexually active people with a particular focus on high risk groups and the poor (STD vouchers) and poor women (safe delivery vouchers)<br />Cost to beneficiaries: - Safe deliveryabout 1,500 Ushs per voucher. Originally estimated at US$1.70 decreased because of depreciation.- STD treatment at 3,000 Ushs (US$1.70) per pair of vouchers – no longer so because of depreciation.<br />OBA subsidy to accredited Medical Service Providers (MSPs) on real cost<br />Commission of approx. US$0.11 per voucher provided to voucher distributors<br />Incentives to VMU (Marie Stopes International-Uganda) to perform KfW-funded behavior-change campaign, marketing and training of MSPs<br />
  19. 19. Structure of Uganda OBA Project <br />
  20. 20. KEY MESSAGE<br />In order to maximize the success of this program, we must use evaluation findings as we learn them to inform the implementation process.<br />The Uganda experience: <br />Learn the importance of using evaluation findings as we discover them, rather than waiting until the end of the project to learn.<br />
  21. 21. REVIEW OF PROJECT BASELINE<br />Baseline survey looked at: <br /><ul><li>Proportion of attended deliveries
  22. 22. Frequency of antenatal and post-natal services
  23. 23. Prevalence of Caesarian delivery
  24. 24. Number of referrals for mothers who have never delivered before in a facility</li></li></ul><li>BASELINE SURVEY METHODOLOGY<br /><ul><li>Surveyed 22 clusters of adjacent villages
  25. 25. Voucher Distributors assigned to two Groups:
  26. 26. Treatment group - in early 2009
  27. 27. Control group -- wait 2 years
  28. 28. Target population: Women and men
  29. 29. Age 15-49
  30. 30. Pregnant or pregnant partner past 12 months
  31. 31. Sample respondents: 2,266 women in 94 villages</li></li></ul><li>BASELINE SURVEY DESIGN<br /><ul><li>Two Step village cluster sampling
  32. 32. Clusters selected randomly out of adjacent villages
  33. 33. Households with pregnancies in past 12 months </li></ul>– identified by local leaders and community health volunteers<br /><ul><li>Cluster sample minimum of 120 pregnant women
  34. 34. Within each cluster, look for change in attitudes and use of facilities for maternal deliveries
  35. 35. Treatment and Control groups have similar access to transportation & contracted facilities
  36. 36. 5-10 kms from 13 contracted facilities
  37. 37. 3 kms from a road connecting them to facility</li></li></ul><li>INITIAL FINDINGS FROM SURVEY<br /><ul><li>No significant differences in use of facilities care: antenatal (ANC), delivery and postnatal (PNC)
  38. 38. Majority of respondents agreed on importance of visiting facility for all care
  39. 39. Each type of facility visit consistently lower than expected use</li></li></ul><li>INITIAL FINDINGS: ANC Visit<br /><ul><li>No differences between treatment and control groups</li></li></ul><li>INITIAL FINDINGS: Delivery<br /><ul><li>Insignificant difference in use of public facilities
  40. 40. Reasons for not using facility: Home births
  41. 41. Distance - 24%,
  42. 42. High cost of care - 22%
  43. 43. Unnecessary to deliver at a facility - 17%
  44. 44. Facility births more common with
  45. 45. Higher household assets
  46. 46. Higher education
  47. 47. Young, first-time mothers </li></li></ul><li>INITIAL FINDINGS:Postpartum Morbidity<br /><ul><li>No significant differences in complications during pregnancy</li></li></ul><li>INITIAL FINDINGS: Issues to Watch<br /><ul><li>Coincidentally, use of services already higher in treatment villages.
  48. 48. Follow-up survey - need to ensure large enough sample of vouchers and number of births
  49. 49. Some evaluation findings have to inform the implementation earlier in the process</li></li></ul><li>WHERE WE ARE<br /><ul><li>Greater use of vouchers for any of the first three ANC visits than PNC
  50. 50. Proportion of C-sections to normal deliveries remained constant within 9-17%, despite large numbers being registered</li></li></ul><li><ul><li>Healthy Baby client visits increased to 43,308 to date</li></ul>Project’s first healthy baby delivered in 2009<br />
  51. 51. WHERE WE ARE<br /><ul><li>July-Sept 2010:
  52. 52. Visits </li></ul>ANC visit 1- 11,661<br /> ANC visit 2 - 9,023 <br /> ANC visit 3 - 5,483 <br /> PNC visits - 2,467 <br /><ul><li>C-Sections: 1,257</li></ul> Pregnancy complications Managed: 3,274 <br />
  53. 53. RESULTS FROM INCEPTION: MID-2009 - SEPTEMBER 2010 <br />23,075 healthy babies delivered (target: 50,456)<br />29, 675 cases of STD treatments (target: 35,000)<br />
  54. 54. CHALLENGES<br /><ul><li>Lower use for ANC and especially PNC than expected
  55. 55. Poor road network & limited access to transport --
  56. 56. hampers referral system
  57. 57. High turnover of medical staff --
  58. 58. led to constraints in quality service provision</li></li></ul><li>NEXT STEPS<br />Goal:<br />Learn How to Implement the Program Better<br />
  59. 59. NEXT STEPS: Improve Feedback Process <br /><ul><li>Include more real-time evaluation tools to understand results better and to adjust more promptly
  60. 60. Follow-up IE Survey in same villages: care was taken to select respondents with a five-year birth history
  61. 61. Qualitative Research – Focus Groups discussions </li></ul>Women<br />Values and beliefs around labor<br />Quality of care in service providers<br />Sensitive Issues: form focus groups of women who trust each other<br />
  62. 62. NEXT STEPS: Improve Feedback Process<br />Qualitative Research – Focus Groups discussions <br />Providers<br />Knowledge and awareness building around the voucher scheme<br />High turnover of medical staff<br />Problems specific to the target group<br />DHO’s<br />Constraints to taking ownership and leadership of the voucher schemes? How can these be increased?<br />User fees: quality of care; sense of ownership of beneficiaries<br />
  63. 63. CONCLUSION<br /><ul><li>There is hope for reproductive care for women in Uganda.
  64. 64. The voucher system can work…if implemented well.
  65. 65. We’ve learned so much from our initial studies.
  66. 66. We are looking forward to improving our evaluation process to learn how to implement most effectively.
  67. 67. We will fine-tune and adjust the program.
  68. 68. We all want fewer tragedies like Joan’s…and more planned successes like Anita and baby…don’t we?</li></ul>Happy mother and baby!<br />
  69. 69. PROJECT AND IMPACT EVALUATION TEAM<br /><ul><li>Project Task Team Leader: Peter Okwero, the World Bank
  70. 70. Transaction Adviser and IE Team Leader: Leslie Villegas, GPOBA
  71. 71. Principal Investigators:
  72. 72. Ben Bellows, PhD
  73. 73. Matt Hamilton, Ms MPH
  74. 74. Baseline Survey Report available upon request</li>

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