uganda health vouchers scheme: the results so far

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REPRODUCTIVE HEALTH VOUCHERS IN WESTERN UGANDA Impact Evaluation

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Page 1: Uganda Health Vouchers Scheme: The Results So Far

REPRODUCTIVE HEALTH VOUCHERS

IN WESTERN UGANDA

Impact Evaluation

Page 2: Uganda Health Vouchers Scheme: The Results So Far

INTRODUCTION

435 women die per 100,000 live births in Uganda.

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.

That’s why we introduced the Health Voucher project: to help Mothers, like Joan, live…and we are convinced that this program can work.

LAUNCH OF HEALTH VOUCHERS

Page 3: Uganda Health Vouchers Scheme: The Results So Far

OVERVIEW

Review baseline survey of Uganda Reproductive Health OBA project

Where We Are: project’s current results, implementation gaps and challenges

Outline next steps for evaluation: Improve the use evaluation findings Thus better inform implementation

Page 4: Uganda Health Vouchers Scheme: The Results So Far

PROJECT OBJECTIVES:Healthy Mothers and Babies

Objectives: 1) To provide safe delivery

packages,

2) to provide non-stigmatizing treatment for STDs

Output: Safe Delivery Packages

4 ante-natal visits

Delivery

1 post-natal visit

GPOBA Grant Amount: US $4.3 million

Page 5: Uganda Health Vouchers Scheme: The Results So Far

Reproductive Health Vouchers in Uganda

(OBA project) 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)

Cost to beneficiaries: - Safe delivery about 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.

OBA subsidy to accredited Medical Service Providers (MSPs) on real cost

Commission of approx. US$0.11 per voucher provided to voucher distributors

Incentives to VMU (Marie Stopes International-Uganda) to perform KfW-funded behavior-change campaign, marketing and training of MSPs

Page 6: Uganda Health Vouchers Scheme: The Results So Far

Structure of Uganda OBA Project

Page 7: Uganda Health Vouchers Scheme: The Results So Far

KEY MESSAGE

In order to maximize the success of this program, we must use evaluation

findings as we learn them to inform the implementation process.

The Uganda experience: Learn the importance of using

evaluation findings as we discover them, rather than waiting until the end

of the project to learn.

Page 8: Uganda Health Vouchers Scheme: The Results So Far

REVIEW OF PROJECT BASELINE

Baseline survey looked at: Proportion of attended deliveriesFrequency of antenatal and post-natal services Prevalence of Caesarian deliveryNumber of referrals for mothers who have never

delivered before in a facility

Page 9: Uganda Health Vouchers Scheme: The Results So Far

BASELINE SURVEY METHODOLOGY

Surveyed 22 clusters of adjacent villages

Voucher Distributors assigned to two Groups: Treatment group - in

early 2009 Control group -- wait

2 years

Target population: Women and men Age 15-49 Pregnant or pregnant partner past 12 months

Sample respondents: 2,266 women in 94 villages

Page 10: Uganda Health Vouchers Scheme: The Results So Far

BASELINE SURVEY DESIGN Two Step village cluster sampling

Clusters selected randomly out of adjacent villages Households with pregnancies in past 12 months

– identified by local leaders and community health volunteers

Cluster sample minimum of 120 pregnant women Within each cluster, look for change in attitudes and

use of facilities for maternal deliveries Treatment and Control groups have similar access to

transportation & contracted facilities 5-10 kms from 13 contracted facilities 3 kms from a road connecting them to facility

Page 11: Uganda Health Vouchers Scheme: The Results So Far

INITIAL FINDINGS FROM SURVEY

No significant differences in use of facilities care: antenatal (ANC), delivery and postnatal (PNC)

Majority of respondents agreed on importance of visiting facility for all care

Each type of facility visit consistently lower than expected use

Characteristics Control Treatment

Important to use ANC (%) 79 84

Use facility for ANC 1+ times (%) 58 60

Important for clinic delivery (%) 77 81

Use facility for delivery (%) 50 53

Important to use PNC (%) 69 72

Use facility for PNC 1+times (%) 27 28

Page 12: Uganda Health Vouchers Scheme: The Results So Far

INITIAL FINDINGS: ANC Visit

No differences between treatment and control groups

Number of ANC visits Control (%) Treatment (%)

0 visits 42 40

1 visits 7 7

2 visits 15 17

3 visits 27 29

4+ visits 10 8

Page 13: Uganda Health Vouchers Scheme: The Results So Far

INITIAL FINDINGS: Delivery

Insignificant difference in use of public facilities Reasons for not using facility: Home births

Distance - 24%,High cost of care - 22% Unnecessary to deliver at a facility - 17%

Facility births more common withHigher household assetsHigher educationYoung, first-time mothers

Page 14: Uganda Health Vouchers Scheme: The Results So Far

INITIAL FINDINGS:Postpartum Morbidity

No significant differences in complications during pregnancy

Characteristics Ever had Excessive Bleeding (%)

Ever had miscarriage or Abortion (%)

Ever had Caesarian Section (%)

Control Group 27 19 6

Treatment Group 26 18 5

Page 15: Uganda Health Vouchers Scheme: The Results So Far

INITIAL FINDINGS: Issues to Watch

Coincidentally, use of services already higher in treatment villages.

Follow-up survey - need to ensure large enough sample of vouchers and number of births

Some evaluation findings have to inform the implementation earlier in the process

Page 16: Uganda Health Vouchers Scheme: The Results So Far

WHERE WE ARE

Greater use of vouchers for any of the first three ANC visits than PNC

Proportion of C-sections to normal deliveries remained constant within 9-17%, despite large numbers being registered

Page 17: Uganda Health Vouchers Scheme: The Results So Far

Healthy Baby client visits increased to 43,308 to date

Project’s first healthy baby delivered in 2009

Page 18: Uganda Health Vouchers Scheme: The Results So Far

WHERE WE ARE

July-Sept 2010: Visits

ANC visit 1- 11,661ANC visit 2 - 9,023 ANC visit 3 - 5,483 PNC visits - 2,467

C-Sections: 1,257Pregnancy complications Managed: 3,274

Page 19: Uganda Health Vouchers Scheme: The Results So Far

23,075 healthy babies delivered (target: 50,456)29, 675 cases of STD treatments (target: 35,000)

RESULTS FROM INCEPTION: MID-2009 - SEPTEMBER 2010

Page 20: Uganda Health Vouchers Scheme: The Results So Far

CHALLENGES

Lower use for ANC and especially PNC than expected

Poor road network & limited access to transport -- hampers referral system

High turnover of medical staff -- led to constraints in quality service

provision

Page 21: Uganda Health Vouchers Scheme: The Results So Far

NEXT STEPS

Goal:

Learn How to Implement the Program Better

Page 22: Uganda Health Vouchers Scheme: The Results So Far

NEXT STEPS: Improve Feedback Process

Include more real-time evaluation tools to understand results better and to adjust more promptly

Follow-up IE Survey in same villages: care was taken to select respondents with a five-year birth history

Qualitative Research – Focus Groups discussions Women

Values and beliefs around laborQuality of care in service providersSensitive Issues: form focus groups of women

who trust each other

Page 23: Uganda Health Vouchers Scheme: The Results So Far

NEXT STEPS: Improve Feedback Process

Qualitative Research – Focus Groups discussions

ProvidersKnowledge and awareness building around the

voucher schemeHigh turnover of medical staffProblems specific to the target group

DHO’sConstraints to taking ownership and leadership

of the voucher schemes? How can these be increased?

User fees: quality of care; sense of ownership of beneficiaries

Page 24: Uganda Health Vouchers Scheme: The Results So Far

CONCLUSION There is hope for reproductive

care for women in Uganda.

The voucher system can work…if implemented well.

We’ve learned so much from our initial studies.

We are looking forward to improving our evaluation process to learn how to implement most effectively.

We will fine-tune and adjust the program.

We all want fewer tragedies like Joan’s…and more planned successes like Anita and baby…don’t we?

Happy mother and baby!

Page 25: Uganda Health Vouchers Scheme: The Results So Far

PROJECT AND IMPACT EVALUATION TEAM

Project Task Team Leader: Peter Okwero, the World Bank

Transaction Adviser and IE Team Leader: Leslie Villegas, GPOBA

Principal Investigators:Ben Bellows, PhDMatt Hamilton, Ms MPH

Baseline Survey Report available upon request