Making Health Systems Work for the Poor

Impact of voucher system on access to MCH services in Eastern

UgandaMakerere University School of Public health

John Hopkins UniversityFHS Uganda

Acknowledgements

DFID Melinda & Gates Foundation District officials FHS Partner Institutions ( JHU, IDS,

ICDDRB, CHEI, UIN,IHMR) Researchers

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Introduction

Access to MCH services has been constrained by geographical, transport and financial barriers.

Most interventions are directed to the supply side.

Despite interventions of building more health units, equipping them and staffing them (HSSP 2010/11-2014/15).

Introduction- continued

Utilization of MCH services has been low - Health facility deliveries (42%) (UDHS 2006) 4th ANC (47%) and PNC within 1st 2 days (23%)

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.

Objectives

To use the voucher system increase access to MCH services

To generate evidence that can inform designing, implementing and scale up of similar innovations.

Methodology

Non randomized trial

4 districts ( Kamuli, Buyende, Pallisa and Kibuku)

2 intervention and 2 control

Intervention: Voucher for transport and maternity child health services

Intervention

Vouchers for

transport

Vouchers for MCH services

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

Cost of service vouchers

Private ($) Public ($)

Pilot PhaseCost Price

ANC 1 0.96 0.72

ANC 2,3&4 1.15 0.86

DELIVERY 5.76 4.32

C/section 57.58 43.19

PNC 1.15 0.86

Implementation phase 1st Cost Price

ANC 1,2,3&4 0.46 0.32

DELIVERY 3.07 2.30

C/section 49.9 24.95

PNC 0.46 0.32

Methods- continued

Data collection methodsQuantitative methods

Health facility recordsHealth worker surveys

Qualitative methodsFocus group discussionsKey informant interviewsCommunity in-depth interviews

Results

4th ANC visits in Intervention and Control districts

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Intervention Control

Results

Health Facility Deliveries in Intervention and Control Districts

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Results1st PNC visits in Intervention and Control Districts

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Intervention Control

ResultsEXPENDITURE OF FUNDS RECEIVED BY THE HEALTH FACILITIES

INFRASTRUCTURE

23%

PERSONNEL

61%DRUGS/SUNDRIES

13%

EQUIPMENT

3%

Results Increased utilisation of facility

deliveries Increased motivation of health

workersImproved working conditionsReadily available at health unitsMonetary incentives

Improved supply of drugs and supplies

Results

Formal & Informal costs of treatment reduced

Improved perceived quality of care

Improved geographical access

Change in health seeking behaviour

Created agents for MCH

Results

Increased community awareness about benefits of facility deliveries

Increased support from the community leaders

Income generating activity for the community

Increased demand for health workers to provide MCH services

Challenges

Inadequate resources-staffing and supplies

Appropriate referral transport Record keeping Timely payments for health units

and transporters Rising fuel costs Sustainability

Lessons learned

The demand for MCH services has been there but has been mired by lack of affordable transport and cost of health services.

Using locally available resources like local transport providers and subsidized health service costs can improve access to health services.

Lessons learned

Such ventures avail resources to health facilities and promote formulation of innovation mechanisms on how to improve MCH service delivery

But community response in terms of uptake of health services in such ventures may overwhelm the available financial and human resources.

Conclusion

Vouchers for MCH and use of available resources within the community can help overcome geographical and financial barriers that hinder access to MCH services.

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.

References

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.

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

Health Sector Strategic Plan III 2010/11-2014/15 (Uganda) 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.

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References

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.

 

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