UPDATE ON THE UGANDA REPRODUCTIVE HEALTH VOUCHER PROJECT (URHVP)

URHVP is a follow up to the successful maternal health voucher scheme (Healthy life and Healthy baby) implemented in Western Uganda from 2008-2012. The project finances the demand side through use of vouchers to reduce the likelihood of out-of-pocket payment for deliveries among women in communities served by the program. The four year Ministry of Health (MOH) project kicked off in September 2015 .It is funded by the Swedish Development Agency (SIDA) ,World Bank ,United Nations Population Fund (UNFPA). It is implemented by Marie Stopes Uganda (MSU) as the Voucher Management Agency (VMA) while BDO is the Independent Verification and Evaluation Agent (IVEA).

URHVP is  implemented in 12 districts of South Western Uganda (Mbarara, Kabale, Kanungu, Ntungamo Kiruhura, Sheema, Buhweju, Mitooma, Ibanda, Isingiro, Bushenyi, Rubirizi) and 13 districts of East and Central Uganda (Jinja, Bugiri Kamuli, Buyende, Kaliro, Luuka, Mayuge, Iganga, Namutumba, Kibuku, Tororo, Namayingo and Busia). The primary beneficiaries are the poor and vulnerable pregnant mothers resident within the catchment areas of the contracted health facilities. The contracted Voucher Service Providers (VSPs) and surrounding communities are the secondary beneficiaries.

The project overall aim is to increase access to skilled care among poor women living in rural and disadvantaged areas during pregnancy and delivery.

The project targets 3 key outputs;

  1. Support 142,400 pregnant women to deliver under skilled attendance;
  2. Out of all the vouchers purchased by pregnant women,70% are redeemed to support deliveries in a health facility;
  3. 90% of pregnant women enrolled under the project attend at least one ante natal care visit (ANC 1).

The project comprises of two components.

  • Package of Safe Delivery Services to Poor Pregnant Women.
  • Capacity Building and Project Management

The package of services consists of: four antenatal visits, safe delivery, one postnatal visit, Family Planning ,treatment and management of selected pregnancy-related medical conditions and complications (including caesarean sections), and emergency transport. The package also includes services for Elimination of HIV transmission from mother to child (eMTCT) as part of antenatal care. The VMA takes lead in implementing component one. The specified services are provided by the contracted VSPs that later submit reimbursement claims together with the appropriate voucher coupons to the VMA for settlement at the negotiated and agreed fees.

The pregnant mothers purchase vouchers at Uganda shillings (UGX) 4,000 (US$1.60) from members of Village Health Teams (VHTs) in their areas of residence. A combination of geographical targeting (based on poverty mapping) and a customized poverty grading tool is used to select eligible beneficiaries.

As at March 2017 a total of 247 health facilities were identified, assessed and contracted from both Public, Private not For Profit (PNFP) and Private for Profit (PFP) as illustrated below.

South  Western Region Eastern Region
Service Type Private (PFP/PNFP) Public Total Service Type Private (PFP/PNFP) Public Total
BEmOC 80 12 92 BEmOC 42 74 116
CEmOC 12 18 30 CEmOC 4 5 9
Total 92(75%) 30(25%) 122 Total 46(37%) 79(63%) 125

Component two supports project management functions including building national capacity to mainstream and scale up implementation of safe delivery voucher scheme in the health sector.

With the direct supervision and guidance from MoH, MSU has trained service providers (midwives) on the Basic Emergency Obstetric Care (BEmOC) package (ALARM) and Post-Partum Family planning (PPFP). The project has also trained Doctors and Anaesthetic officers in Comprehensive Emergency Obstetric Care (CEmOC) services.

Vouchers that Make Having a Baby Safe and Cheap for More Ugandan Women

Uganda has affordable health care for some of its poorest women.

Uganda has affordable health care for some of its poorest women.

STORY HIGHLIGHTS
  • A UShs4,000 (US$1) voucher covers antenatal visits, delivery, and post-natal care
  • Vouchers are intended for poorer women in two mostly rural regions of Uganda
  • Even the cost of assisted births, such as Caesareans, are covered

KANUNGU, May 30, 2017 – Anna Katushabe’s daughter came into the world in early May by Caesarean-section delivery, and so both mother and daughter spent longer than expected in Rugyeyo Community Hospital. Ordinarily, the longer stay would have been a worry for the young mother; for Anna, however, her C-section delivery cost only UShs 4,000, just over US$1.

The secret to keeping safe childbirth cheap lies in an innovative voucher programme that gives pregnant women affordable, effective medical attention. When she was four months pregnant, Anna bought a reproductive health care voucher for UShs 4,000. This gave her access to a health facility throughout her pregnancy, and she knew it would cover the delivery and medical care for six weeks after her baby’s birth as well.

Rugyeyo hospital is in Kanungu District, 260 miles (420km) from Kampala on Uganda’s border with the Democratic Republic of the Congo. A normal (vaginal) birth usually costs UShs 46,000 (US$13) at the hospital, while Caesarean births cost UShs 316,000 (US$88).

Uganda was the first country in Eastern Africa to use these health vouchers, starting with a pilot programme in 2006.

Funded by KfW, the German Development Bank, the pilot project, Healthy Life, subsidised the cost of treating sexually transmitted infections. The scheme expanded in 2008, when KfW and the World Bank’s Global Partnership on Output-Based Aid gave it US$6.2 million to subsidize safe deliveries as well.

The program in south-western Uganda was very successful, helping with nearly 66,000 deliveries, 130% of its initial target. Uganda’s Ministry of Health then expanded it to other districts through its Reproductive Health Voucher Project, which was funded with US$13.3 million from the Swedish International Development Agency (SIDA) through the Global Partnership on Output Based Aid (GPOBA).


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Giving birth in remoter rural areas

More than 200,000 vouchers have since been sold in 25 districts in south-western Uganda and central-eastern Uganda. Marie Stopes Uganda manages the distribution of vouchers, and a poverty-grading tool is designed to help the program reach the most vulnerable women.

The project’s objective is to increase the amount of access poorer women living in disadvantaged rural areas have to skilled medical care. It covers the cost of:

  • four antenatal visits,
  • a safe delivery under skilled supervision,
  • one postnatal visit,
  • the treatment and management of some pregnancy-related medical conditions and complications, including Caesarean-sections
  • and emergency transport.

“This program started at our facility in May 2016,” Dr. Hadus Masereka, the medical superintendent at the hospital. “About 40 out of the 50 pregnant women who have ended-up delivering by C-section since, have had vouchers.” This saved the lives of women who would have been unable to afford this expensive, often emergency, procedure. Many Ugandan women deliver their babies in sometimes less-than-ideal conditions at home.

Such new health initiatives are helping reverse Uganda’s high rates of infant and maternal mortality, with maternal mortality falling from 438 to 336 deaths for 100,000 live births between 2011 and 2016, according to the Uganda Bureau of Statistics. Infant mortality has also fallen from 432 deaths to 54 per 1000 live births.

The voucher system shows that with a little money and innovation, the process of giving life does not have to be a matter of life and death for Ugandan mothers like Anna. By the end of March 2017, the project had provided help for more than 43,000 births, including 31,000 normal deliveries, 6,500 assisted deliveries, and 5,600 C-sections.

In some areas, the system has also reduced the burden public health care facilities face when it comes to childbirth care, because vouchers have made private, for-profit health centres accessible to women.

About the Uganda Reproductive Health Voucher Project

The Uganda Reproductive Health Voucher Project increases skilled medical care during pregnancy and delivery for poor women living in rural and disadvantaged areas.