Increasing access to institutional deliveries using demand and supply side incentives: early results from a quasi-experimental study

Elizabeth Ekirapa-Kiracho,Peter Waiswa,David Serwadda,Gorette Nalwadda,Olico Okui,Aloysius Mutebi,M Hafizur Rahman,John Bua,David H Peters,Elizeus Rutebemberwa,George W Pariyo,Fred Makumbi,Noah Kiwanuka

doi:10.1186/1472-698x-11-s1-s11

Elizabeth Ekirapa-Kiracho, Peter Waiswa + Show 11 more

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https://doi.org/10.1186/1472-698x-11-s1-s11

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Abstract

BackgroundGeographical inaccessibility, lack of transport, and financial burdens are some of the demand side constraints to maternal health services in Uganda, while supply side problems include poor quality services related to unmotivated health workers and inadequate supplies. Most public health interventions in Uganda have addressed only selected supply side issues, and universities have focused their efforts on providing maternal services at tertiary hospitals. To demonstrate how reforms at Makerere University College of Health Sciences (MakCHS) can lead to making systemic changes that can improve maternal health services, a demand and supply side strategy was developed by working with local communities and national stakeholders.MethodsThis quasi-experimental trial is conducted in two districts in Eastern Uganda. The supply side component includes health worker refresher training and additions of minimal drugs and supplies, whereas the demand side component involves vouchers given to pregnant women for motorcycle transport and the payment to service providers for antenatal, delivery, and postnatal care. The trial is ongoing, but early analysis from routine health information systems on the number of services used is presented.ResultsMotorcyclists in the community organized themselves to accept vouchers in exchange for transport for antenatal care, deliveries and postnatal care, and have become actively involved in ensuring that women obtain care. Increases in antenatal, delivery, and postnatal care were demonstrated, with the number of safe deliveries in the intervention area immediately jumping from <200 deliveries/month to over 500 deliveries/month in the intervention arm. Voucher revenues have been used to obtain needed supplies to improve quality and to pay health workers, ensuring their availability at a time when workloads are increasing.ConclusionsTransport and service vouchers appear to be a viable strategy for rapidly increasing maternal care. MakCHS can design strategies together with stakeholders using a learning-by-doing approach to take advantage of community resources.

Highlights

Geographical inaccessibility, lack of transport, and financial burdens are some of the demand side constraints to maternal health services in Uganda, while supply side problems include poor quality services related to unmotivated health workers and inadequate supplies
In Uganda, studies have shown that the main reasons for women not delivering in a health facility include: overall financial limitations, long distances to health facilities coupled with transport difficulties, lack of decision making power among women, inability to afford the medical supplies that are often compulsory at public health facilities, rude health workers, and preference for traditional child birth positions [4,5,6,7]
Since there is evidence to show that attendance of delivery by skilled health personnel reduces maternal mortality [24], this pilot study demonstrates that vouchers may be an effective way to rapidly increase institutional delivery in rural areas, and thereby help achieve Millennium Development Goal (MDG) 5

Summary

Introduction

Geographical inaccessibility, lack of transport, and financial burdens are some of the demand side constraints to maternal health services in Uganda, while supply side problems include poor quality services related to unmotivated health workers and inadequate supplies. To demonstrate how reforms at Makerere University College of Health Sciences (MakCHS) can lead to making systemic changes that can improve maternal health services, a demand and supply side strategy was developed by working with local communities and national stakeholders. In Uganda, studies have shown that the main reasons for women not delivering in a health facility include: overall financial limitations, long distances to health facilities coupled with transport difficulties, lack of decision making power among women, inability to afford the medical supplies that are often compulsory at public health facilities, rude health workers, and preference for traditional child birth positions [4,5,6,7]. Some of the reasons given include distance from facilities, leakage of resources away from the diseases common among the poor, ignorance of treatment options, and cultural and household constraints [10]

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