Understanding the Incremental cost of Increasing Access to Maternal Health Care Services: Perspectives from a Voucher Scheme in Eastern Uganda

C. Mayora, E. Ekirapa-Kiracho, F. Ssengooba , S.O. Baine, O. Okui

Acknowledgements• DFID• Gates Foundation• MU-JHU• District officials• Health workers• FHS Partners ( JHU, IDS, ICDDRB, CHEI, UIN,IHMR)

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Introduction • In Uganda e.g. only 41% deliver at health

facilities, 42% supervised deliveries, even then only 20% of facility deliveries are from rural areas, and 27% from lower SEQ

• Yet, up to 75% of deaths can be averted by ensuring timely access to obstetric care and related maternal care-WHO

• To address these issues, a voucher scheme was launched by FHS, to try and address these challenges as well as investigate impact of DSF and SSF to service uptake

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Introduction Indeed evidence shows that vouchers

schemes are increasingly being used to subsidise vulnerable populations to access critical services, e.g. in Nicaragua(STIs), Bangladesh(RH), Cambodia, and Kenya, and Uganda

However, limited studies have been conducted to ascertain the cost-effectiveness of these voucher/subsidy schemes, especially in developing countries

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AIM In this paper, we estimate incremental costs

of efforts through subsidization(vouchers) of increasing access to maternal healthcare, drawing from a voucher scheme implemented in Eastern Uganda

We however underscore the limitations attributed to CEA, that relate to under-estimation of the wider economic effects of interventions, including total economic benefits resulting from for example life-saved

Voucher Scheme package voucher entitled pregnant women to

transport to and from health facility

Entitled pregnant mother to package of maternal services, ANCs ( Pilot), Delivery and PNC.

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Voucher scheme package Health system strengthening component

that included training of health workers, provision of basic equipment, drugs and supplies and support supervision.

Costs of transport for a return trip on average ranged from USD1.8-USD4.5

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Cost price of Health Services(USD)

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Service Pilot Phase(De’9-may’10)

Implementation(ju’10-fe’11)

Implementation (mar’11-de’11)

Gv’t PNFP Gv’t PNFP Gv’t PNFP

ANC1 0.9 1.14 0.4 0.55 0.4 0.55

A2,3,4 1.0 1.36 0.4 0.55 0.4 0.55

DEL 5.1 6.82 2.7 3.64 4.1 5.45

C/S 51.1 68.18 29.5 59.09 27.3 54.55

PNC 1.0 1.36 0.4 0.55 0.5 0.55

Methodology We use the ingredients approach for costing

Costs included are from the provider’s perspective

Costs are captured for the implementation

year (June2010-June 2011)

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Cost CategoriesCOST CATEGORY DESCRIPTION

Voucher costs Transport and service voucher reimbursements, voucher printing, distribution, and transporters’ identification prints(cards)

H. S. Strengthening Health workers’ trainings, procurements of basic equipment, drugs and supplies and regular support supervisions.

Sensitization &mobilization Stakeholder workshops at community, facility and district levels, talk shows and radio messaging, printing of posters production of documentary, hire of film vans, etc.

Administrative costs Costs relating to personnel, field coordination, field supervision, planning activities, regular scheme reviews by faculty, etc..

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Methodology We collect costs from project

accountabilities and financial records Estimate the average transport cost for

deliveries by looking at number of women transported and total transport vouchers costs

Estimate the incremental costs by calculating additional costs and additional effects

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Results:Summary costs on voucher reimbursement

Activity Amount (Ug. Shs)

Amount (USD)

Total cost

Service Vouchers 87,680 95,866

Admin costs for payment

4135

Contingencies 241

Printing vouchers 3809.8

Transport vouchers 174,666.08 185,376

Admin costs 4793

Contingency 482.85

Printing vouchers 3809.8

Printing Identification cards

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Results: Summary costs on Health System Strengthening

Activity Amount(USD)

Equipment , drugs, sundries 101,822

Support Supervision 13,917

Training of Health Workers 8,973

Training materials 616

Total 125,328

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Results: Summary Distribution of costs by major activity(Percentage Distribution)

Activity Amount(USD) Percentage

Service voucher costs 95,866 19.1

Transport Voucher costs 185,376 36.9

Health Systems Strengthening 125,328 24.9

Sensitization and mobilization 46,396 9.2

Administration 49,869 9.9

Total 502,835 100.00

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Graph showing share of key-scheme activity costs as % of total costs

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Service vouchers reimbursed in intervention period

Service Total Percentage of total

ANCs 6302 15.9

Delivery 22558 57.0

PNC 9678 24.4

C-Section 213 0.5

False Labour 810 2.0

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Results

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Total cost transport vouchers ( excluding referral transport)

No of women transported

Cost per woman transported

$183,439 39,348 $4.6

Results

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Incremental cost for deliveries

Additional deliveries

Incremental cost per additional institutional delivery

$304,248 19,288 $15.7

Incremental cost for PNC’s

Additional PNC visits

Incremental cost per additional PNC

$102,352 7452 $13.73

Conclusion Incremental costs per additional delivery

and PNC appear small However cost of scaling up such a scheme

in a large population with high fertility ( 6.7) likely to be huge offering a challenge to sustainability in a developing country facing competing priorities

To ensure the success of voucher scheme, health system strengthening must be put in place, to guarantee quality outcomes

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Policy Implication Finding ways of mobilizing existing

community resources and taking advantage of technology ( eg e payment)may enhance sustainability by reducing administrative costs, funding for scheme

Policy makers must therefore carefully design such a subsidy policy cognizant of its financial implications, feasibility and sustainability of the policy.

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