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.

  • 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).


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.

Maternal health voucher initiative opens doors for safe deliveries

“I feel so happy that I was able to deliver my baby safely. I received good care and attention from the health workers here; my baby and I were in good hands,” says Alice Nalubwama from her bed in the maternity ward at Kamuli Mission Hospital in Eastern Uganda. “When I was referred here from the clinic I was worried because I felt my baby was in danger. But the doctors here helped me and I delivered safely.” The 24 year old delivered her fourth child by caesarean section. With her new born in her arms and her mother by her side, she smiles broadly as a midwife conducts a ward round checking on Nalubwama and other new mothers.

What may sound like a routine and ordinary event is often not the case for women like Nalubwama in many parts of Uganda. Even though the recently released Uganda Demographic and Health Survey (UDHS) shows that about 7 out of 10 women now deliver with the help of a skilled professional, there are still pockets of inequality especially in rural areas. There, having a baby is not always an easy journey and for many women the costs involved are a prohibitive factor; many end up delivering at home or with unqualified birth attendants who cannot handle complicated deliveries.

With her first three children, Nalubwama says she and her husband, who are peasant farmers, had to use up all their savings so that she could attend ante-natal care and deliver at a private clinic near her home.

As a way to address the challenges faced by women like Nalubwama, a new initiative, the Maternal Health Voucher Scheme was introduced. The Scheme is one component of the Reproductive Maternal Newborn and Child Health Country Engagement plan, implemented by UNFPA, WHO and UNICEF. One of the objectives is to ensure availability and utilization of high impact maternal health interventions at birth and during the postnatal period. The beneficiaries include women and men in 30 districts where maternal mortality is still high and access to good quality services for women during pregnancy and delivery is still a challenge.

In eight districts in Eastern Uganda, UNFPA supports partner Marie Stopes Uganda to implement the Maternal Health Voucher scheme. Rolled out in June 2016, the initiative is implemented in 100 public and private health facilities that are accredited by Marie Stopes to provide maternal health services. The scheme works through a network of 200 trained volunteer health workers (Village Health Teams) who are a critical link to the health system. The VHTS identify needy prospective mothers and sell them vouchers at 4,000 shillings. (About $1). They also provide information to pregnant women on the importance of attending at least four ante natal care visits and delivering at a health facility.

The voucher card allows the mother to access services throughout pregnancy and delivery, with just one single payment. Once a mother buys the voucher she is entitled to four ante-natal care visits, delivery under the care of a skilled health professional and post-natal care. For women who develop complications, an ambulance is available to ensure there are no delays in getting them to a higher level facility where they can receive more specialised care.

This is exactly what happened in Nalubwama’s case. At the Health Centre III where she was originally meant to have her baby, the health workers were concerned that her labour was not progressing well. “The midwife said that my contractions were weak and that I may not be able to push the baby out. I was so worried; I did not know what would happen next,” Nalubwama recalls.

Realising that she might need a caesarean section the health workers quickly referred her by ambulance to the bigger and better equipped Kamuli Mission Hospital where the caesarean section was performed. Ordinarily the operation would have cost about 500,000 shillings, not counting the cost of transport to the hospital. Nalubwama and her family paid nothing.

For Dr Andrew Muleledhu, the Medical Superintendent of Kamuli Mission Hospital, the fact that Nalubwama and others like her are able to access such services is testament to the power of the Voucher Scheme. “At the heart of it the voucher system is addressing poverty. That voucher is money in the hands of the mother. It is preventing this mother and her family from going into financial catastrophe simply because they are having a baby. That is universal health coverage at its best,” he says.

Sister Jane Nelima a midwife at Mayuge Health Centre III one of the facilities where the Voucher Scheme operates could not agree more. She explains that as a midwife she is happy that with the Voucher Scheme she is able to see more mothers coming to the ante natal care clinic and coming back to deliver at the facility.

To date, 1,939 women in the eight districts where the Voucher Scheme is implemented have been supported to deliver at a health facility, attended to by trained and skilled health workers. A total of 14,999 vouchers have been sold, meaning that many more mothers will be receiving critical maternal health care in months to come.

As for Nalubwama, the only thing that could top her experience of having a safe delivery was the thought of getting back home to her husband and other children and introducing the new addition to the family.

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