A voucher for your antenatal

It is late afternoon as Amina Namususwa walks slowly from the labour ward to the outpatients’ shed of Mayuge Health Centre (HC) III in Mayuge town. Her husband dropped her at the HC the previous morning after she developed malaria. After an hour, he returned to their home in Bukawongo village – a distance of about 20 miles. Now, 30 hours later, she is experiencing early labour. The 20-year-old unemployed mother is about to deliver her second baby.

Namususwa and her 22-year-old husband are farmers, hiring themselves out to dig in other people’s gardens for a daily income of Shs2,000. With these earnings, in case Namususwa develops complications during the delivery, it would be impossible for her to pay the Shs300,000 needed for an emergency c-section. Thus, enters the Uganda Reproductive Health Voucher Project (URHVP), a programme implemented by Marie Stopes Uganda (MSU) and supported by the United Nations Population Fund (UNFPA).

In 2015, UNFPA benefited from a Country Engagement Grant aimed at contributing to the reduction of maternal, neonatal and child mortality in Uganda. The target beneficiaries of the Grant include women and men of reproductive age, pregnant women, newborns and children under five in 30 high burden districts in the three regions of Karamoja, Western, and Busoga. These regions were chosen because they are hard to reach and have poor maternal, new born, and child indicators.

The goal of URHVP is to reduce maternal mortality among poor pregnant women caused by geographical and financial barriers, through increased access to medical care during pregnancy, delivery and the postnatal period. The project was implemented in Busoga region in July 2016 in both public and private health facilities. Health workers in the private facilities were trained, accredited and monitored by Marie Stopes Uganda.

To the rescue
“I heard about the voucher project from a friend who had used it before,” Namususwa says, lifting her voucher, continuing, “she said the voucher helps poor women to have good medical services, so I bought it at Shs4,000.”

Namususwa’s voucher entitles her to four visits at the HC: antenatal visits, normal delivery, monitoring after the birth, and one postnatal visit that includes family planning and counselling. More importantly, though, in case of an emergency situation, she can be transported – with medical personnel – to a better health facility for a C-section performed free-of-charge.

The vouchers are sold by Voucher Community Based Distributers (VCBDs), who are also Village Health Team (VHT) members. They move around from village to village explaining the benefits of the vouchers and selling them to expectant mothers.

This follows an initial exercise using a poverty grading scale to determine who fits the criteria of being poor in a disadvantaged area. The vouchers can only be used for a defined package of services from contracted health facilities.

“Before the introduction of the vouchers, the situation was terrible,” Jane Nerima, an enrolled midwife says, adding, “Mothers were delivering at traditional birth attendants’ homes while others were giving birth at home. In our monthly reports, on average, about 90 women were delivering at the HC. Now, the number has shot up to 130 women.”

The downside of the upsurge in numbers is that most first time mothers are teenagers. “They are a problem but our work is to enable them have a safe delivery,” Nerima says, continuing, “Since they are risky mothers, we refer them for c-sections early.”

The upsurge brought on by the URHVP can be evidenced in the high number of pregnant women attending health facilities. For instance, on average, Kamuli Mission Hospital now performs 100 C-sections in a month on women referred from other health facilities. Previously, the hospital was only performing 30 c-sections monthly. At Kamuli General Hospital, 91 per cent of pregnant women attend their first antenatal visit as compared to 60 per cent in June 2016. Unfortunately, only 47 per cent attend the fourth antenatal visit.

Dr Aggrey Batesaaki, the district health officer of Kamuli District, says the URHVP has improved the attitude of midwives towards expectant mothers. “Midwives are no longer as harsh as they used to be. If the VHT has encouraged women to come to the hospital, all the health workers have no choice but to be courteous because they know they are paid according to the number of mothers they deal with.”

The contracted health facilities, after providing the defined package of services to pregnant women, submit claim forms along with the appropriate number of voucher coupons to the Voucher Management Agency for settlement of the negotiated fees.
Dr John Gambani, clinical officer, Mayuge HCIII says there has also been an improvement in transport logistics to cater for those referred to other hospitals. “The ambulances are always available and we only refer to hospitals that have been accredited in the voucher system. These hospitals should have a functional blood bank and have the personnel to perform c-sections. In our case, we refer to Buluba, Iganga, Nyenga, and Bugiri Hospitals. Before the referral is made, we have a dialogue with the patient and if they opt for an unaccredited hospital, they have to pay for the c-section.”

The challenges of the URHVP
As any good system, there are bound to be problems in the beginning. “The payments from Marie Stopes take long to come to the accredited health facilities and when they arrive there are no clear guidelines on how they will be utilised,” Dr Batesaaki says, continuing, “This can easily lead to misuse of the funds with the clinical officers declaring less money to the district.” Because of the delay in distribution of funds, Kamuli Mission Hospital (a private not-for-profit hospital) suspended the referral services it was offering for a month in February 2017.

This came at a great disadvantage to critically ill mothers who had been referred for c-sections. They were turned away to seek help in other facilities. The services have since been restored.

Another challenge is that the VCBDs do not give proper sensitisation to the beneficiaries. A rural woman automatically assumes her voucher will cater for all her health needs, the baby’s needs, baby clothes and transport back home; yet this is not the case. Some women buy the vouchers and keep them for when they will get pregnant yet the vouchers have fixed expiry dates.

“Some VHTs sell the vouchers – at Shs60,000 to Shs100,000 – to unscrupulous people who are quite capable of paying for their health needs,” Dr Batesaaki says, adding, “If a woman only delivers through c-section, which costs about Shs600,000 in a private facility, her husband will buy the voucher at a high price so that his wife will deliver free-of-charge. This puts poor women at a disadvantage.”

Dr Andrew Muleledhu, medical superintendent, Kamuli Mission Hospital, faced challenges with working out the details of a referral. “Sometimes, when a mother is referred, she could have lost her delivery coupon. You have to call the regional supervisor to get the reference number of her voucher. You need the reference number before you can perform a c-section. She has been brought in a bad state and needs immediate attention, yet you have to wait for the number. Sometimes, a mother would arrive at 11pm, when the regional supervisor is asleep.

Fortunately, we are now permitted to operate without the reference number.” Currently, the district has run out of vouchers, and according to Kevin Magoba, an enrolled midwife in Kamuli Mission Hospital, they have been permitted to work on women who have expired vouchers.

URHVP helping to fulfill SDGs
In Busoga region, 200 VCBDs were trained to provide information and education through interpersonal communication. A total of 14,999 vouchers have been sold. Of these, 10, 032 women have had at least one antenatal visit and 1,939 women have received skilled care at delivery. There are currently 100 accredited health facilities in the region providing basic and comprehensive emergency obstetric care.

Sustainable Development Goal Three is about the health and wellbeing of the global population. Target One is aimed at reducing the global maternal mortality to less than 70 per cent per 100,000 live births by 2030. Overall, the voucher project is transforming maternal mortality in the country because it is addressing poverty. To rural women, the voucher is like a form of currency helping them access the quality health care services they would normally not afford.