The fifth Millennium Development Goal (MDG) is to reduce maternal mortality by seventy five percent. The demographic health surveys done in Uganda indicate that maternal mortality has been persistently high (527 in 1995, 505 in 2000, and 435 in 2005) [1
]. There is evidence to show that attendance at delivery by skilled health personnel reduces maternal mortality [2
], but over one half of all women in developing countries do not have a skilled birth attendant at delivery [3
]. In Uganda the proportion of mothers delivering in health facilities has been persistently low (38% in 1995, 37% in 2001 and 41% in 2006), but the rates are even lower in rural areas and among the poorest quintile of the population [1
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
]. As in many other countries, maternal health services have typically been provided by both the public sector and the private sector. The public sector in Uganda has several shortfalls which include a shortage of health workers, inadequate supplies, unofficial charges, and unsympathetic health workers [8
]. Financing of health services is mainly through tax based public subsidies’ although the literature shows that the poor often do not benefit from public subsidies. 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
Ensuring access to quality maternal health care services throughout pregnancy and childbirth is therefore essential. Lack of proper provision of essential obstetric care services has potential life threatening effects, and may lead to serious complications which require expensive specialized treatment that is extremely costly relative to disposable income [11
]. However, access to such services for the poor is often limited [12
]. Some attempts have been taken to increase institutional deliveries from the supply side. These include training of midwives in safe motherhood and life saving skills; construction of level IV Health Centres that are expected to offer emergency obstetric care; and training of comprehensive nurses who can offer both midwifery and nursing care. However, there have been no concerted efforts to intervene on the demand side.
Financing of maternal health services is also largely supply based, is not directly linked to the quantity or quality of services, and does not consider the provider’s ability to reach vulnerable populations. The nature of maternal health services makes it imperative that financially sustainable strategies are put in place to ensure access. Financing of health care may involve demand or supply side approaches. When supply side approaches are used, resources are allocated to a supplier so that they can provide particular services based on the cost of inputs. Utilizing the demand side approach, financing is made through patients, giving them the purchasing power so that providers are then paid based on the quantity and/or quality of services they provide [13
]. A combined demand and supply side based system of financing, where facilities are partly funded based upon their ability to provide services to targeted populations, may result in improved benefits for the poor and vulnerable.
Innovations in financing such as conditional cash transfers, vouchers, provider subsidies and equity funds may have the potential to increase access to health services by the poor [12
]. Demand side approaches often utilise vouchers. Consumers are given a written entitlement which can be exchanged for a specified service up to a pre-determined amount at accredited facilities. Alternatively, consumers are told to claim a given service from a provider who then claims payment directly from the financing agency [13
]. Pearson defined such consumer led demand side financing mechanisms as a “transfer of purchasing power to specified groups for defined goods and services” [17
]. Experience suggests that demand side financing using vouchers has a potential to provide more targeted services to the poor [13
]. A study in Nicaragua showed that vouchers could substantially increase the use of services for sexually transmitted infections, demonstrating that many adolescents were willing to use such services if readily accessible [18
]. In Tanzania the use of vouchers increased the use of insecticide treated nets (ITN) among pregnant women [19
]. In Bangladesh they reported increased deliveries attended by skilled birth attendants among the poor [20
]. Furthermore, it has been suggested that competitive voucher schemes are able to target subsidies more accurately, provoke demand for under used services, and may lead to improvements in technical quality [21
Although consumer led demand side financing can be used in a number of different ways to further public policy objectives, it is important to note that its implementation requires a concerted effort to address various pitfalls. Others have noted that such schemes may lead to over servicing where providers provide more services than necessary because of the link between the outputs and the finances earned. These schemes are also prone to cream skimming where providers choose to offer services to clients who have fewer problems. In addition the transaction and administration costs for implementing the scheme can be particularly high [21
]. Geographic accessibility of services and a multiplicity of providers are also essential to ensure that the target group obtains a desired service [13
Mechanisms for increasing awareness about the scheme must also be put in place. In the Tanzania study the voucher return rate was extremely high at 97% (7720/8000). However, two years after the start of the program awareness among target groups was only 43% [19
]. Additional pre-requisites for success included a strong administrative capacity for implementation, an accreditation system or at least a system of ensuring quality of care in health facilities involved in the program, and a methodology and capacity for identifying target groups [13
]. In summary, the available literature shows that voucher schemes are a potentially effective means of targeting health services to specific population groups such as pregnant women, children under five, or the poorest. However, most voucher schemes to date have been implemented on a small scale. There is limited documented evidence of their successes or of the feasibility and cost implications for scaling up pilots [13
MakCHS is undergoing a transformation with the aim of playing a stronger role in improving health outcomes in Uganda. We present here a study that was designed to demonstrate how ongoing reforms of the College can lead to new ways in which the College can work with local stakeholders, to influence the health system, with the ultimate aim of improving health status in Uganda. At the time of writing, the study is still in progress, but early results on the use of services are available from the routine information systems and are presented.
The intention of the study is to assess the effectiveness of a specific demand and supply side financing system using vouchers to increase use of maternal health services at health units. The information obtained will be used to guide decisions that are geared at promoting the attainment of the 5th MDG. It is envisioned that the availability of increased research evidence in this area will encourage greater use of cost-effective lifesaving interventions. The primary research questions for the study are: Does providing a financial incentive (a voucher for institutional delivery and a voucher for transport to access antenatal, delivery and postnatal services) increase antenatal, institutional delivery, and postnatal attendance, using public, private-not-for-profit (PNFP), and private-for-profit (PFP) health facilities?
Our hypotheses are that women in areas where the intervention is provided are more likely to deliver in health facilities, attend more antenatal and postnatal care compared to women in areas where no intervention is offered. Broadly, the study is designed to
1. Identify the demand side factors that influence delivery at health facilities.
2. Evaluate the effectiveness of a service and transport voucher system in increasing deliveries at public, PNFP and PFP health facilities, and among the poor in particular.
3. Identify the pathways through which vouchers influence delivery care services at public, PNFP and PFP health facilities.
4. Estimate the incremental cost of implementing a voucher system to increase deliveries at health facilities.
Since the study is ongoing at the time of writing, in this article we provide detailed information on the study protocol, and report on the early results on the use of antenatal, delivery, and post-natal services. We also discuss the lessons learned by the implementers in how to design and implement this type of strategy that involves closely working with rural communities.