Post on 13-Jun-2015
REPRODUCTIVE HEALTH VOUCHERS
IN WESTERN UGANDA
Impact Evaluation
INTRODUCTION
435 women die per 100,000 live births in Uganda.
Joan did not stop bleeding after giving birth, her husband left her with his mother-in-law to fetch a doctor. After 3 hours and twenty miles of biking in the dark under the pouring rain, he and the doctor reached Joan, but she had passed away.
That’s why we introduced the Health Voucher project: to help Mothers, like Joan, live…and we are convinced that this program can work.
LAUNCH OF HEALTH VOUCHERS
OVERVIEW
Review baseline survey of Uganda Reproductive Health OBA project
Where We Are: project’s current results, implementation gaps and challenges
Outline next steps for evaluation: Improve the use evaluation findings Thus better inform implementation
PROJECT OBJECTIVES:Healthy Mothers and Babies
Objectives: 1) To provide safe delivery
packages,
2) to provide non-stigmatizing treatment for STDs
Output: Safe Delivery Packages
4 ante-natal visits
Delivery
1 post-natal visit
GPOBA Grant Amount: US $4.3 million
Reproductive Health Vouchers in Uganda
(OBA project) Targeting: Geographic (20 districts) and self-selection: all sexually active
people with a particular focus on high risk groups and the poor (STD vouchers) and poor women (safe delivery vouchers)
Cost to beneficiaries: - Safe delivery about 1,500 Ushs per voucher. Originally estimated at US$1.70 decreased because of depreciation.
- STD treatment at 3,000 Ushs (US$1.70) per pair of vouchers – no longer so because of depreciation.
OBA subsidy to accredited Medical Service Providers (MSPs) on real cost
Commission of approx. US$0.11 per voucher provided to voucher distributors
Incentives to VMU (Marie Stopes International-Uganda) to perform KfW-funded behavior-change campaign, marketing and training of MSPs
Structure of Uganda OBA Project
KEY MESSAGE
In order to maximize the success of this program, we must use evaluation
findings as we learn them to inform the implementation process.
The Uganda experience: Learn the importance of using
evaluation findings as we discover them, rather than waiting until the end
of the project to learn.
REVIEW OF PROJECT BASELINE
Baseline survey looked at: Proportion of attended deliveriesFrequency of antenatal and post-natal services Prevalence of Caesarian deliveryNumber of referrals for mothers who have never
delivered before in a facility
BASELINE SURVEY METHODOLOGY
Surveyed 22 clusters of adjacent villages
Voucher Distributors assigned to two Groups: Treatment group - in
early 2009 Control group -- wait
2 years
Target population: Women and men Age 15-49 Pregnant or pregnant partner past 12 months
Sample respondents: 2,266 women in 94 villages
BASELINE SURVEY DESIGN Two Step village cluster sampling
Clusters selected randomly out of adjacent villages Households with pregnancies in past 12 months
– identified by local leaders and community health volunteers
Cluster sample minimum of 120 pregnant women Within each cluster, look for change in attitudes and
use of facilities for maternal deliveries Treatment and Control groups have similar access to
transportation & contracted facilities 5-10 kms from 13 contracted facilities 3 kms from a road connecting them to facility
INITIAL FINDINGS FROM SURVEY
No significant differences in use of facilities care: antenatal (ANC), delivery and postnatal (PNC)
Majority of respondents agreed on importance of visiting facility for all care
Each type of facility visit consistently lower than expected use
Characteristics Control Treatment
Important to use ANC (%) 79 84
Use facility for ANC 1+ times (%) 58 60
Important for clinic delivery (%) 77 81
Use facility for delivery (%) 50 53
Important to use PNC (%) 69 72
Use facility for PNC 1+times (%) 27 28
INITIAL FINDINGS: ANC Visit
No differences between treatment and control groups
Number of ANC visits Control (%) Treatment (%)
0 visits 42 40
1 visits 7 7
2 visits 15 17
3 visits 27 29
4+ visits 10 8
INITIAL FINDINGS: Delivery
Insignificant difference in use of public facilities Reasons for not using facility: Home births
Distance - 24%,High cost of care - 22% Unnecessary to deliver at a facility - 17%
Facility births more common withHigher household assetsHigher educationYoung, first-time mothers
INITIAL FINDINGS:Postpartum Morbidity
No significant differences in complications during pregnancy
Characteristics Ever had Excessive Bleeding (%)
Ever had miscarriage or Abortion (%)
Ever had Caesarian Section (%)
Control Group 27 19 6
Treatment Group 26 18 5
INITIAL FINDINGS: Issues to Watch
Coincidentally, use of services already higher in treatment villages.
Follow-up survey - need to ensure large enough sample of vouchers and number of births
Some evaluation findings have to inform the implementation earlier in the process
WHERE WE ARE
Greater use of vouchers for any of the first three ANC visits than PNC
Proportion of C-sections to normal deliveries remained constant within 9-17%, despite large numbers being registered
Healthy Baby client visits increased to 43,308 to date
Project’s first healthy baby delivered in 2009
WHERE WE ARE
July-Sept 2010: Visits
ANC visit 1- 11,661ANC visit 2 - 9,023 ANC visit 3 - 5,483 PNC visits - 2,467
C-Sections: 1,257Pregnancy complications Managed: 3,274
23,075 healthy babies delivered (target: 50,456)29, 675 cases of STD treatments (target: 35,000)
RESULTS FROM INCEPTION: MID-2009 - SEPTEMBER 2010
CHALLENGES
Lower use for ANC and especially PNC than expected
Poor road network & limited access to transport -- hampers referral system
High turnover of medical staff -- led to constraints in quality service
provision
NEXT STEPS
Goal:
Learn How to Implement the Program Better
NEXT STEPS: Improve Feedback Process
Include more real-time evaluation tools to understand results better and to adjust more promptly
Follow-up IE Survey in same villages: care was taken to select respondents with a five-year birth history
Qualitative Research – Focus Groups discussions Women
Values and beliefs around laborQuality of care in service providersSensitive Issues: form focus groups of women
who trust each other
NEXT STEPS: Improve Feedback Process
Qualitative Research – Focus Groups discussions
ProvidersKnowledge and awareness building around the
voucher schemeHigh turnover of medical staffProblems specific to the target group
DHO’sConstraints to taking ownership and leadership
of the voucher schemes? How can these be increased?
User fees: quality of care; sense of ownership of beneficiaries
CONCLUSION There is hope for reproductive
care for women in Uganda.
The voucher system can work…if implemented well.
We’ve learned so much from our initial studies.
We are looking forward to improving our evaluation process to learn how to implement most effectively.
We will fine-tune and adjust the program.
We all want fewer tragedies like Joan’s…and more planned successes like Anita and baby…don’t we?
Happy mother and baby!
PROJECT AND IMPACT EVALUATION TEAM
Project Task Team Leader: Peter Okwero, the World Bank
Transaction Adviser and IE Team Leader: Leslie Villegas, GPOBA
Principal Investigators:Ben Bellows, PhDMatt Hamilton, Ms MPH
Baseline Survey Report available upon request