To reduce cases of women dying just because they dared to get pregnant, the UNFPA and its partners are using a voucher system to get mothers deliver in hospital free of charge, writes ABUBAKER MAYEMBA.
At 4:30pm on a Wednesday, two pregnant women sit on a short bench in a dark corridor at Mayuge health centre III, expecting to be assisted by health workers at a records table in the extreme corner.
Holding a huge pink registration book that matches her dress, a midwife rushes in with apologies. She immediately turns her attention to the last woman in the queue, who is writhing in pain. She grabs a pink-and-blue card from her, and declares that she is to be admitted.
Although not in palpable pain, Susan Noreen Kagoya looks on, wishing that it was her to be admitted instead so that her torture ends and she holds her baby. For nearly nine months, this girl has carried in her womb a baby whose father literally fled once he learnt that he had impregnated a schoolgirl.
Kagoya met Alex, a youthful policeman, during her primary seven vacation; now at 16, she is expecting her first child. She is unsure if she will be able to fend for her child, since she sometimes fails to find what to eat. The eldest child in a family of seven, Kagoya has seen her parents struggle to put their children in school – although some dropped out because of lack of money.
“My parents were bitter with me at first but later they supported me since there was nothing else to do,” she says. “I wish that I could give birth to a daughter and also continue with my education. I worry about what to eat but not about delivery because I bought a voucher card and doctors monitor me.”
Despite biting poverty in the regions of Busoga, Karamoja and western Uganda, many pregnant women are using their pink-patterned blue cards to access antenatal, delivery, and post-natal services in health centres.
According a release signed by to Dr Yvonne Kizza Mugerwa, the project facilitator at the United Nations Population Fund (UNFPA), the Uganda Reproductive Health Voucher Card project started in 2016 with the aim ofreducing child and maternal mortality. She says after identifying 30 districts that had poor reproductive maternal newborn and child health indicators (RMNCH indicators), UNFPA worked with the Health ministry on a plan to bring the numbers down.
To ensure that poor expectant mothers don’t die during delivery, over $1 million and $13 million has been pumped into the voucher card project by UNFPA and the World Bank respectively.
The healthcare charity Marie Stopes got funding to train village health team members (VHTs), community-based distributors (CBDs) and identify health facilities, both private and public, capable of providing modern maternal care. Under the system, an expectant mother receives antenatal and post-natal services free of charge from any health facility of their choice.
Kagoya, who bought the voucher card at Shs 4,000 from a VHT, expects to give birth at Mayuge health centre III. Four of the stickers on her card have been peeled off and the remaining two are for the birth and postnatal visit. Marie Stopes will cover all her bills and if she is to undergo caesarean, as the midwives here predict, then the agency will have to pay the Shs 500,000 charged at Francis hospital Buluuba.
“So far, 14,999 vouchers have been sold. Of these, 10,032 women have had at least one antenatal clinic visit. 1,939 women so far have received skilled care at delivery and the number is expected to rise,” Mugerwa says.
sixty kilometres west of Mayuge is Kamuli district, one of the places in Busoga where one needs not to look hard to see evidence that people here live on less than a dollar a day. Due to the fertility rate being 6.7 in Kamuli, there is competition for the little vital resources like health care and food.
For Dr Aggrey Batesaaki, the Kamuli district health officer (DHO), providing vouchers and family planning education is a great initiative that is timely. He observes that health care within the district has greatly improved because health workers are sensitive to patients’ needs.
This, he says, is because they know that the higher the number of patients handled, the higher the earnings. Several private clinics have also taken up family planning services since they get support and have started to sensitise communities about the benefits of planning for a smaller family.
Batesaaki says now that many facilities offer free family planning methods like implants and bilateral tubal ligation (BTL), many people in Kamuli have embraced it, with the district’s family planning uptake now at 23.2 per cent.
“We have seen very poor mothers benefiting from very good services from private clinics like Kamuli Mission hospital. They wouldn’t have had that opportunity if they didn’t have the voucher card because at Shs 4,000, she is able to access the best hospitals,” Batesaaki says.
“Services have improved because we have seen midwives calling mothers to come for antenatal. We were at 68 per cent last year but now 91 women [out of every 100] who get pregnant report for the first antenatal.”
On the outskirts of Kamuli town stands the church-owned Kamuli Mission hospital, one of the facilities accredited by Marie Stopes to handle maternal and family planning cases. Here, Dr Alex Muleedhu, the hospital’s medical superintendent, reveals that admissions of women with voucher cards has gone up.
This, he reasons, is because most expectant mothers in Kamuli and surrounding districts like Luuka and Kaliro wished they could one day deliver their babies at Kamuli Mission and the vouchers gave them that opportunity.
Records here show that from September to December 2016, caesarean referrals increased from 35 to 100. Voucher card referrals stood at 53 for the month of February.
Yet both experts agree that although the voucher system will go a long way in reducing child and maternal mortalities, there are still a few loopholes that need to be worked upon. Muleedhu says that sometimes verification of authentic voucher holders becomes hard since it requires calling the regional supervisor to confirm. He says because of this, many expectant mothers go through a lot of pain as the hospital authorities authenticate their documents.
“Voucher cards are issued out to cater for specific conditions but sometimes you get unclear incidents. For instance, a mother comes and says I have the voucher but I lost the delivery sticker, I have to call and confirm but the mum is bleeding. There are those grey areas,” observes Muleedhu.
Batesaaki, on the other hand, says many VHTs don’t send out the right message, which leads to many people assuming that the card guarantees free food, clothing and free treatment for all ailments. He adds that some women buy the cards and keep them hoping they will use them during their next pregnancy not knowing that they expire.
William Nyombi, the programme manager of Marie Stopes, maintains that they have tried to minimise the loopholes. He agrees that despite the fact that some VHTs have not communicated the right information, they have sent another team of well-trained officers to engage the beneficiaries.
To address the ‘grey areas,’ Nyombi says they agreed with all the 247 partner health facilities that under unclear circumstances, the mother should always be provided with services so long as she has the voucher. He adds that to minimise impersonators, they follow the poverty assessment forms and sometimes make unannounced visits to beneficiaries to ascertain their incomes.
For three years, poor women in rural areas will continue to receive free antenatal and postnatal services so long as they own a voucher card. Currently, according to the World Health Organisation (WHO), Uganda’s maternal mortality ratio (MMR) stands at 343 per 1,000 live births. UNFPA estimates that by September 19, 160,000 women will have benefited from the Voucher card system thus reducing the MMR.
For poor expectant mothers like Kagoya, the voucher card guarantees that no matter the complications of their pregnancies, they will be able to access the best facilities at only Shs 4,000.