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Experiences of Implementing a Demand Side Financing Scheme for Maternal Health Services in Eastern Uganda

Bua John 1 , Ekirapa –Kiracho E1, Nalwadda G2, Rahman H 3, Peters D3, Bishai D3 , Pariyo G 1, Mutebi A 1 , Okui O 1.

1. Makerere University School of Public Health, Department of Health Policy Planning and Management 2. Makerere University School of Medicine, Department of Nursing 3. Johns Hopkins University Bloomberg School of Public Health, Department of International Health

Introduction

Geographical accessibility and the lack of appropriate transport are demand-side constraints for use of maternal health care services in Uganda. Coupled with this is the poor quality of services related to inadequate supplies and unmotivated health workers. Additionally it is common for mothers who are aware of the benefits and need to use maternal health services to lack the means to pay for transport and services. These factors combined together contribute to the low percentage of institutional deliveries (42%). Most interventions in Uganda have been directed at addressing the supply side constraints but not the demand side. But literature suggests that demand side financing may have the potential to increase access of targeted services to vulnerable groups such as pregnant women. However evidence about the use of demand side financing in sub Saharan Africa is still limited.

Objective

Methodology

Design : Non randomized trial

Setting: 4 districts ( Kamuli, Buyende, Pallisa & Kibuku) 2 intervention and 2 control

Intervention: Voucher for transport and maternity services Health system strengthening

Positive experiences

•Increased utilization of maternal health services

•Increased motivation of health workers

Challenges

•Organizing appropriate referral transport

•Inadequate resources – Staffing, supplies, equipment

•Record keeping

•Security at night

•Timely payments for the health facilities and transport providers

•Implementation of the multiple components of the project.

•Sustainability

Lessons learned

Acknowledgements

•Demand for services has been there but access has been hindered by various factors including transport.

•Using available resources within the community can help over come hindrances to access of health services.

•There is need to address gaps in health staffing by the District and its partners to maintain a positive trend.

•Response from such interventions may outstrip the available resources.

•DFID

•Mellinda &Gates Foundation

•MU-JHU Twining Programme

•Ministry of Health Uganda

•Kamuli and Pallisa District officials

•The Communities of Kamuli and Pallisa District

•FHS Partner Institutions

•Researchers

The Future Health Systems Study in Uganda is using both demand (vouchers for transport and maternal services) and supply side initiatives (training health workers and provision of essential equipment, drugs and supplies) to generate evidence that can inform the designing and implementation of similar schemes.

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Figure 2: A mother with a newborn being taken home by a transporter in Buyende District.

DELIVERIES FOR BOTH THE INTERVENTION AND CONTROL ARMS FOR 2009/10 IN KAMULI DISTRICT

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1st PNC VISITS IN INTERVENTION AND CONTROL ARMS FOR 2009/10 IN KAMULI DISTRICT

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Figure 5: Health workers conducting an MCH clinic in Kamuli District.

•Increased community awareness

•Increased community participation through sensitising and providing transport services •Increased support from the community leaders

•Income generating activity for the community

•Increased demand for health workers to provide services

Figure 6: Newborns delivered in Kamuli District Hospital

Figure 1: Map of Uganda showing Kamuli and Pallisa