An assessment of opportunities and challenges for public sector involvement in the maternal health voucher program in Uganda

Abstract

BackgroundContinued inequities in coverage, low quality of care, and high out-of-pocket expenses for health services threaten attainment of Millennium Development Goals 4 and 5 in many sub-Saharan African countries. Existing health systems largely rely on input-based supply mechanisms that have a poor track record meeting the reproductive health needs of low-income and underserved segments of national populations. As a result, there is increased interest in and experimentation with results-based mechanisms like supply-side performance incentives to providers and demand-side vouchers that place purchasing power in the hands of low-income consumers to improve uptake of facility services and reduce the burden of out-of-pocket expenditures. This paper describes a reproductive health voucher program that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the program to include public sector facilities.MethodsData presented here describes the results of interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher program in southwestern Uganda. Interviews were transcribed and organized thematically, barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the program by involving public sector facilities were investigated.ResultsThe findings show that access to sexual and reproductive health services in southwestern Uganda is constrained by both facility and individual level factors which can be addressed by inclusion of the public facilities in the program. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher program with other services is likely to address some of the barriers. The public sector facilities were also seen as being well positioned to provide voucher services because of their countrywide reach, enhanced infrastructure, and referral networks. The voucher program also has the potential to address public sector constraints such as understaffing and supply shortages.ConclusionsAccrediting public facilities has the potential to increase voucher program coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening linkages between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilization of resources to support the sustainability of the programs. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher program.

Demand-side financing for maternal and newborn health: what do we know about factors that affect implementation of cash transfers and voucher programmes?

“…vouchers for maternity care services (Bangladesh’s Maternal Health Voucher Scheme [ 79 – 84 ], a pilot programme in Bangladesh [ 85 ], a voucher programme in Cambodia [ 86 , 87 ], the Chiranjeevi Yojana in India [ 88 – 92 ], Kenya’s Vouchers for Health programme [ 93 – 102 ], pilot programmes in Pakistan [ 103 , 104 ], and the HealthyBaby vouchers [ 105 , 106 ] and Mekerere University Voucher Scheme in Uganda [ 107 , 108 ]), and vouchers for merit goods (the Tanzanian National Voucher Scheme [ 109 – 111 ]).…”

Use of mobile phone consultations during home visits by Community Health Workers for maternal and newborn care: community experiences from Masindi and Kiryandongo districts, Uganda

“…Mobile phone consultation can save time, reduce the financial burden and other social costs that women would otherwise incur if they had to travel to the health centre to consult with professional health workers. This is encouraging because distance and cost of travels have often been cited as a limitation for utilization of maternal and newborn care services [ 35 – 39 ].…”

Does a voucher program improve reproductive health service delivery and access in Kenya?

“…Voucher programs have the potential to reduce gaps in equitable healthcare utilization by subsidizing low-income individuals’ purchasing power [ 11 ]. Voucher programs provide an economic incentive to accredited facilities by reimbursing them for services offered [ 13 ]. By doing so, the program can stimulate a market for the services and may generate greater competition between providers and indirectly motivate improvements in quality of services.…”