An assessment of opportunities and challenges for public sector involvement in the maternal health voucher program in Uganda

Health Research Policy and Systems

Ben Bellows¹  Ian Askew¹  Charlotte Warren¹  Teresah Bange²  Timothy Abuya¹  Rebecca Njuki¹  Francis Obare¹  Lucy Kanya¹  Jerry Okal¹ 

[1] Population Council, Ralph Bunche Road, P.O. Box 17643, Nairobi 00500, Kenya;Independent Consultant, Box 2753, Nairobi 00100, Kenya

关键词: Vouchers;    Reproductive health;    Public sector engagement;    Output-based approach;    Opportunities;    Maternal health;    Challenges;   

Others  :  805123
DOI  :  10.1186/1478-4505-11-38

 received in 2013-03-22, accepted in 2013-10-09,  发布年份 2013

【 摘 要 】

Background

Continued inequities in coverage, low quality of care, and high out-of-pocket expenses for health services threaten attainment of Millennium Development Goals 4 and 5 in many sub-Saharan African countries. Existing health systems largely rely on input-based supply mechanisms that have a poor track record meeting the reproductive health needs of low-income and underserved segments of national populations. As a result, there is increased interest in and experimentation with results-based mechanisms like supply-side performance incentives to providers and demand-side vouchers that place purchasing power in the hands of low-income consumers to improve uptake of facility services and reduce the burden of out-of-pocket expenditures. This paper describes a reproductive health voucher program that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the program to include public sector facilities.

Methods

Data presented here describes the results of interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher program in southwestern Uganda. Interviews were transcribed and organized thematically, barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the program by involving public sector facilities were investigated.

Results

The findings show that access to sexual and reproductive health services in southwestern Uganda is constrained by both facility and individual level factors which can be addressed by inclusion of the public facilities in the program. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher program with other services is likely to address some of the barriers. The public sector facilities were also seen as being well positioned to provide voucher services because of their countrywide reach, enhanced infrastructure, and referral networks. The voucher program also has the potential to address public sector constraints such as understaffing and supply shortages.

Conclusions

Accrediting public facilities has the potential to increase voucher program coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening linkages between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilization of resources to support the sustainability of the programs. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher program.

【 授权许可】

   
2013 Okal et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Fund for Population Activities (UNFPA), World Bank: Maternal mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA and World Bank. Geneva; 2007.
• [2]AbouZahr C, Wardlaw T: Maternal mortality at the end of a decade: signs of progress? Bull World Health Org 2001, 79:561-56.
• [3]Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, Laura D-L, Lofgren KT, David P, Charles A, Lopez AD, Christopher JLM: Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet 2011, 378:1139-1165.
• [4]Barros AJD, Ronsmans C, Axelson H, Loaiza E, Bertoldi AD, França GVA, Bryce J, Boerma JT, Victora CG: Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries. Lancet 2012, 379:1225-1233.
• [5]Prata N, Montagu D, Jefferys E: Private sector, human resources and health franchising in Africa: policy and practice. WHO 2005, 83(83):274-279.
• [6]Houweling TA, Ronsmans C, Campbell OM, Kunst AE: Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries. Geneva 2007, 85:745-754.
• [7]Lawn JE, Lawn JE, Kerber K, Enweronu Laryea C, Massee B: Newborn survival in low resource settings – are we delivering? BJOG 2009, 116:49-55.
• [8]Campbell OM, Graham WJ: Strategies for reducing maternal mortality: getting on with what works. Lancet 2006, 368:1284-1299.
• [9]Graham WJ, Bell JS, Bullough CHW: Can skilled attendance at delivery reduce maternal mortality in developing countries? In Safe Motherhood Strategies: A Review of the Evidence. Edited by De Brouwere VVL, Van Lerberghe W. Antwerp: ITG Press; 2001:97-129.
• [10]Leahy E, Madsen J, Bergeson L, Bernstein J: Maternal Health Supplies in Uganda. Washington, DC: Population Action International; 2010.
• [11]Uganda Bureau of Statistics (UBOS) and ICF International Inc: Uganda Demographic Health Survey 2011. Kampala: OBOS and Calverton, Maryland: ICF international Inc; 2012.
• [12]Uganda Bureau of Statistics (UBOS) and ICF International Inc: Uganda Demographic Health Survey 2006. Kampala: OBOS and Calverton, Maryland: ICF international Inc; 2007.
• [13]World Bank: Better Health for Women and Families: The World Bank’s Reproductive Health Action Plan 2010–2012. Washington, DC: World Bank; 2010.
• [14]Bellows NM, Bellows BW, Warren C: Systematic Review: the use of vouchers for reproductive health services in developing countries: systematic review. Trop Med Int Health 2011, 16:84-96.
• [15]Obare F, Charlotte C, Njuki R, Abuya T, Sunday J, Askew I, Bellow B: Community-level impact of the reproductive health vouchers programme on service utilization in Kenya. Health Policy Plan 2013, 28(2):165-175.
• [16]Gorter AC, Grainger C, Okal J, Bellows B: Systematic Review of Structural and Implementation Issues of Voucher Programs. Analysis of 40 Voucher Programs In-depth Analysis of 20 Programs. Nairobi: Population Council; 2012.
• [17]Bellows NM, Bellows BW, Warren C: Systematic Review: the use of vouchers for reproductive health services in developing countries: systematic review. Tropical Med Inter Health 2011, 16:84-96.
• [18]Meyer C, Bellows N, Campbell M, Potts M: The Impact of Vouchers on the Use and Quality of Health Goods and Services in Developing Countries: A Systematic Review. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London; 2011.
• [19]Gorter AC, Segura ZE, Savelkoul PHM, Morré SA: Chlamydia trachomatis infections in Nicaragua: Preliminary results from a competitive voucher scheme to prevent and treat sexually transmitted infections and HIV/AIDS among sex workers. Drugs Today 2006, 42(Suppl A):47-54.
• [20]Reproductive Health Vouchers Evaluation Team: Evaluation of the population-level impact of the maternal health voucher program in Uganda, Technical Report. Nairobi: Population Council; 2012.
• [21]Ahmed S, Khan MM: Is demand-side financing equity enhancing? Lessons from a maternal health voucher scheme in Bangladesh. Soc Sci Med 2011, 10(72):1704-1710.
• [22]Agha S: Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan. Reprod Health 2011, 8:10. BioMed Central Full Text
• [23]Kanya L, Obare F, Abuya T, Okal J, Njuki R, Warren C, Askew I, Bellows B: Safe Motherhood Voucher Coverage in Western Uganda: Addressing Finance Related Access Barriers.Health Policy and Planning. 2013, 1-8. doi:10.1093
• [24]Bart J, Por I, Maryam B, Peter Leslie A, Wim Van D: Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Health Pol Plann 2012, 27:288-300.
• [25]O’Donnell O: Access to healthcare in developing countries: breaking down demand side barriers. Cadernos de Saude Publica 2007, 23(12):2820-2834.
• [26]Patton MQ: Qualitative Evaluation and Research Methods. 3rd edition. Thousand Oaks, CA: Sage Publications, Inc.; 2002.
• [27]Silverman D: Qualitative Research: Theory, Method and Practice. 2nd edition. London: Sage Publications, Inc.; 2004.
• [28]Orem JN, Zikusooka CM: Health financing reform in Uganda: how equitable is the proposed National Health Insurance scheme? Int J Equity Health 2010, 9:23. BioMed Central Full Text
• [29]Uganda Bureau of Statistics: Uganda National Household Survey: Report on the Socio-Economic Survey 2005/2006. Kampala: Uganda Bureau of Statistics; 2006.
• [30]Ministry of Health: The Second National Health Policy: Promoting people’s health to enhance socio-economic development. Kampala: Ministry of Health; 2010.
• [31]Ministry of Health: National Health Accounts: Tracking resource flows into the health systems in Uganda for the financial year 2008/09 and financial year 2009/10. Kampala: Ministry of Health; 2013.
• [32]Thaddeus U, Maine D: Too far to walk: maternal mortality in context. Soc Sci Med 1994, 38:1091-110.
• [33]Ammoti-Kaguna B, Nuwaha F: Factors influencing choice of delivery sites in Rakai district of Uganda. Soc Sci Med 2000, 50:203-13.
• [34]Afsana K, Rashid SF: The challenges of meeting rural Bangladeshi women’s needs in delivery care. Reprod Health Matters 2001, 9:79-88.
• [35]Musoke MGN: Maternal Health Care in Rural Uganda: Leveraging Traditional and Modern Knowledge Systems. Washington, D.C: World Bank; 2002. https://openknowledge.worldbank.org/bitstream/handle/10986/10798/multi0page.pdf?sequence=1 webcite. Accessed on August 2013
• [36]Kyomuhendo GB: Low use of maternity services in Uganda: impact of women’s status, traditional beliefs and limited resources. Reprod Health Matters 2003, 11:16-26.
• [37]Amone J, Asio S, Cattaneo A, et al.: User fees in private non for-profit hospitals in Uganda: a survey and intervention for equity. Int J Equity Health 2005, 4:6. BioMed Central Full Text
• [38]Uganda Bureau of Statistics (UBOS), Macro International Inc: Uganda Demographic and Health Survey 2006. Calverton, Maryland, USA: UBOS and Macro International Inc.; 2007.
• [39]Ir P, Horemans A, Souk D, van Damme W: Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia. BMC Pregnancy and Childbirth. 10:1.Essendi H, Mills S, Fotso J-C. 2010. Barriers to formal emergency obstetric care services utilization. J Urban Health 2010, 88:356-369. Suppl. 2 doi: 10.1007/s11524-010-9481-1
• [40]Gabrysch S, Cousesens S, Cox J, Campbell OMR: The influence of distance and level of care on delivery place in rural Zambia: a study linked national data in a geographic information system. PLos Medicine 2011, 8(1):e1000394. Doi:10.1371/journal.pmed.100394
• [41]Njuki R, Okal J, Warren CE, et al.: Exploring the effectiveness of the output-based aid voucher program to increase uptake of gender-based violence recovery services in Kenya: a qualitative evaluation. BMC Public Health 2012, 12:426. BioMed Central Full Text
• [42]Ministry of Health Uganda: Situation Analysis of Village Health Teams in Uganda. Kampala: MoH Uganda; 2009.
• [43]Netsayi MN, Undie CC: Formative Evaluation: Presidential Initiative on AIDS Strategy for Communication to Youth – Final Report. New York: Population Council; 2009.
• [44]Nutley S, Walter I, Davies H: Using Evidence: How Research can Inform Public Services. Bristol: The Policy Press; 2007.
• [45]United Nations: The Millennium Development Goals Report 2009. New York: UN; 2009.
• [46]Abuya T, Njuki R, Warren CE, Okal J, Obare F, Kanya L, Askew I, Bellows B: A policy analysis of the implementation of a reproductive health vouchers program in Kenya. BMC Public Health 2012, 12:540. BioMed Central Full Text