A voucher system for prenatal care in Uganda helps thousands of women give birth safely and more affordably.

According to a 2006 study, about 435 women die per 100,000 live births in Uganda because of lack of access to health service facilities and professional healthcare. The high cost of healthcare in Uganda, where most people live on less than a dollar a day, remains a significant obstacle. The Global Partnership on Output-Based Aid (GPOBA), a partnership program administered by the World Bank, is using output-based aid (OBA) to extend access to safe delivery services for poor mothers through public-private partnerships (PPPs). Vouchers for maternal care link payment of public funding directly to the delivery of specific services, in this case a “safe delivery” package of four prenatal visits, a delivery attended by a trained medical professional, and one postnatal visit.

A new approach to an old problem

Hoima—a tranquil district located 203 kilometers from Kampala—is one of 20 districts participating in a pilot project to help poor communities gain access to reproductive health services via a voucher system. In Hoima, women like Grace Nyakato, a 37-year-old mother of three who is pregnant with her fourth child, can buy the “safe delivery” voucher for about $1.20. She uses the voucher to pay for services at local clinics.

GPOBA, working with Uganda’s Ministry of Health, subcontracted Marie Stopes International (Uganda) (MSI) to implement the project. MSI accredits local clinics that offer services to patients in exchange for the pre-paid vouchers. This arrangement was first tested in Uganda by KfW (Germany’s development agency), also a partner in the OBA plan.

These OBA vouchers are achieving results, according to Peter Okwero, World Bank Task Team Leader for the Reproductive Health Vouchers in Western Uganda project. “By using the voucher scheme, women have been empowered to choose their preferred service providers; the providers have increased revenues, and they have recorded major improvements in knowledge and clinical practice as well as quality of care,” he said.

Once approved services have been delivered, clinics submit claims for payment to MSI. Mobile phones can be used to manage the claims process. A GPOBA grant of over $4 million makes vouchers affordable for the poor by paying the difference between actual cost of services and the amount people are willing or able to pay. Grace and other mothers-to-be pay about $1.20, for a voucher. Services cost from around $24 to around $78 for more complicated cases.

Leslie Villegas, GPOBA adviser for the project, emphasized that women became aware about the health vouchers through the project’s communications campaign. Campaign activities focused on the target beneficiaries, emphasized behavior change messages, and promoted voucher value. Communications efforts built on relations with community groups.

Local service providers

Sister Kerezin, a midwife, runs Uganda’s nonprofit St. Jude Thaddeos clinic, one of the small, local service providers that have made the OBA partnership possible. The clinic serves an estimated 50,000 people, mostly refugees from the Congo and Sudan and internally displaced people from Northern Uganda. The facility is a one block-long building housing offices, a maternity ward, and a general ward where wall partitions are made of papyrus mats.

Sister Kerezin encourages expectant mothers to buy a voucher as soon as they know they are pregnant. She observes that the “safe delivery” package has made it easier to “monitor a pregnancy from the beginning to the end,” helping avoid preventable tragedies.

Delivering results

Justine Asaba, a 28-year-old mother of four, is also a project beneficiary. Asaba dropped out of primary school after HIV/AIDS claimed both her parents, and she was forced to marry at an early age. She receives little financial support from her husband and cannot afford private healthcare. Asaba was able to obtain quality care for her last pregnancy through the OBA voucher system. As she explained to GPOBA: “At first I could not believe it when they told me about it [the voucher system]. So I went to the Local Council leaders to ask for more information and I was referred to the clinic where I found other women who were using this service.” The OBA voucher was “sent from heaven” for her, she said. She made use of all of her prenatal appointments and gave birth to a healthy baby boy.

So far, over 34,000 babies have been safely delivered to mothers participating in the OBA voucher system. By the time the pilot ends in December 2011, 136,000 women will have received a range of reproductive health services from maternal care to screening and treatment for sexually-transmitted diseases.