Just a few years ago, Caroline Tino, a resident of the rural eastern Uganda district of Pallisa did not know that in 2010 she would deliver her twins in a health facility. In Caroline’s community, most women deliver at home or in the hands of traditional birth attendants.
The reasons for not delivering in a health facility are several. But the main ones in Uganda include financial limitations, long distances to health facilities coupled with lack of access to transport facilities, lack of decision making power among women, inability to afford the medical supplies that are often compulsory at health facilities, rude unmotivated health workers and preference for traditional child birth settings.
For Caroline, all this changed thanks to the Safe Deliveries Study project being implemented by the Future Health Systems (FHS) Research Consortium. This study is aimed at increasing access to safe delivery services.
“Going for antenatal and delivery at the health facility was catered for by the project (safe deliveries) and it was the same for postnatal care. I also did not pay for the services and medicines as is the case at most health facilities,” said Caroline, a proud mother of healthy twins.
Caroline was lucky not to be among the 6000 Ugandan women who die every year from preventable pregnancy and child birth related complications. Yet, if women could only deliver under skilled care, about 80 percent of these deaths could be prevented, according to reproductive health experts in Uganda.
According to Dr Elizabeth Ekirapa-Kiracho, the safe deliveries study principal investigator, with most interventions being directed at addressing supply-side constraints, the study set up both demand (vouchers for transport and maternal services) and supply-side initiatives (training health workers and provision of essential equipment, drugs and supplies). The ultimate outcome was to generate evidence that could inform the design and implementation of similar schemes.
“These vouchers help a mother access transport and maternal services easily,” explains Dr Ekirapa-Kiracho. “The mother then gives this voucher to a transport provider when she needs to go to the health facility for antenatal care, delivery or post-delivery care. And they often use locally available transport which is often motor cycles (popularly known as boda boda).”
By using the boda boda within the current health system context, the safe deliveries study is trying to evaluate innovative yet locally appropriate solution to help mothers deliver under skilled care, especially in health facilities. Though there were some concerns about the safety of putting pregnant women on the back of boda bodas, they were selected because they were the only available and reliable means of transport in that area. Initially, various transport options besides motor cycles- like cars and bicycles- were part of the scheme, but they were dropped after the pilot when it was found they were rarely used.
For the project to succeed, the study team saw the need to involve stakeholders, as Dr Ekirapa – Kiracho explains: “The community was consulted about the study. Similarly, the transporters, community leaders, district administrative, political and health officials were also engaged at the beginning and have been updated through the study period.”
The engagement has been mainly through meetings, workshops, and face-to-face interactions.
To implement the intervention, vouchers and registers for the vouchers were distributed to participating 22 health facilities in the districts of Kamuli and Pallisa. Drugs, supplies and equipments were procured and distributed to all participating health facilities to supplement the requirements for safe, clean deliveries. In addition, payments were made to transporters once every two weeks after they had submitted their transport vouchers. Health units also received payments once a month according to the number of service vouchers collected during that period.
The pilot phase was for 3 months from December 2009 to February 2010. And by the end of the pilot only conducted in Kamuli District, health facilities were already overwhelmed by the surge in numbers seeking maternal services. The number of number of facility deliveries was less than 200 per month but this increased to more than 500 per month.
For the period March to May 2010 the project continued to give vouchers and made adjustments in the design in preparation for the implementation phase that began in June 2010. During the pilot, the study incurred high costs especially for transport vouchers, health workers were overwhelmed and couldn’t handle the load of patients. As a result, explains Dr Ekirapa-Kiracho, “Transport fares were revised from a flat to a sliding scale so that it varied according to distance travelled. The benefit package was also reduced from ANC+ delivery + PNC to cover only delivery and PNC.”
The positive study outcomes in the pilot were equally registered in Pallisa where health facility deliveries went up. At Kasodo Health Centre, for instance, in the month of May2010 hospital deliveries stood at 9 but that figure shot up to 47 by September, according to the Pallisa District Health Visitor Mary Putan.
Equally for post natal care services within the first seven days after childbirth, attendance went up following community sensitization. Initially, women who had just given birth did not utilize the service due to lack of awareness about its importance combined with other factors like lack of funds for transportation to the health facility.
Findings from the pilot phase and first six months of the one year implementation period saw an upward surge in mothers attending the first postnatal visit.
However, building the capacity of participating health centres through staff training, provision of transport and cash incentives to healthcare workers created an environment that further endeared mothers to health facilities. All these aimed at health system strengthening.
“Unlike in the past, the attitude of health workers has changed a lot. The midwives were very helpful and this treatment has restored my faith in health facilities,” says Rose Abbo, a study beneficiary, whose observation corroborates findings from formatives studies at the start of FHS Phase 1. The formative studies indicated that lack of equipment and motivation to work in remote facilities had turned health workers into rude service providers, putting off many women.
one-the-less, Radio talk shows, Radio spot messages, posters about the scheme and services offered, film van shows with evening sensitization meetings also helped attract women to the project.
The study coordinator Dr John Bua adds that the project has seen local governments in the respective implementation districts recruit additional staff in some health facilities to cope with the overwhelming numbers of women seeking maternal services.
Dr Bua further says that another surprise outcome so far is the case of transporters turning into behavior change agents and mobilizers. “Apart from working with the project to generate some income, they became ambassadors of change as well. They started educating women on the importance of delivering in hospital. We found this interesting and beneficial to the study.”
But it has not been a rosy picture all through. The intervention continues to generate a high demand for health services which is overwhelming the few health workers, drugs and supplies available. There is no access to appropriate referral transport such as an ambulance in the intervention area.
Ensuring that health facility records are kept updated remains an issue as the few health workers available have to clerk, treat and also enter the records. There is no adequate lighting at night in some health facilities to ensure security for the health workers majority of them female. The ever rising fuel prices forced the project to revise the pay of transporters leading to discontent among some.
And the big one, having found the intervention to be costly in terms human resource, logistics, time and funds, are such interventions sustainable? The second phase of the Future Health Systems Research Consortium, now in the planning stage, will focus on developing on a more sustainable mechanism of financing and managing the project so that the gains can be sustained.