Changing incentives for health
workers through a voucher scheme
for maternal health services
Ekirapa- Kiracho E1, Kiwanuka SN 1,
Ruairi B 2, Sengooba F 1, Thomas S 3
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Chraic Scholarship Program
Irish Aid
DFID and Future Health Systems Consortium
Maker ere University School of Public health
Trinity College Dublin
Royal College of Surgeons
Outline
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Introduction
Methods
Results
Discussion
Policy implications
Introduction and background
• MMR- 435 per 100,000 live births
• Utilization of MCH services has been low Health facility deliveries (42%) (UDHS 2006)
4th ANC (47%) and PNC within 1st 2 days (23%)
• Constraints on the demand side and supply
side
• Demand and supply side interventions to
increase access to MCH services
Intervention
Maternal child health services
Vouchers
for MCH
services
Vouchers
for
transport
Pregnant
women in
control
Training
Supervision
Supplies,
drugs and
equipment
Maternal child health services
Pregnant
women in
Intervention
Aims
• The intention of this study was to explore
changes in the incentives for providers and
their influence on the behaviour of providers
Methods
• Study design - case study design
• Study site – Kamuli and Pallisa districts
• The study population - health workers, community
leaders and women of reproductive age
• Data was collected using key informant interviews
(health workers – 25 and community leaders- 13)
and 16 focus group discussions (women of
reproductive age) prospectively
• Coding and Analysis – assisted by Nvivo
Incentives for health workers
-Increased allowances, top ups
-Increased income for facilities
“Am very happy one Hundred times. The money that
is the reality I would even have gone away”
Improved working conditions
-Resources( supplies, equipment,
infrastructure)
“Like this money that we recently got I bought some
scrubing brush, liquid soap, Jik and then moppers. I
saw that it was encouraging the staff because we used
to use hand brooms, compound brooms for scrabing
the ward. At least when you have this one it
encourages the staff.”
Increased job enrichment
- acquisition of new skills- diversity of
patients
- patients to work on
“If you are a mid wife and mothers come to deliver
you just enjoy to work you will just know that you
are working but when you just sit there Idle you even
forget some complications of labour and then you
mess up and because you take time to deliver and
when they come you get the chance to know other
complications”
Incentives for health workers
Increased team spirit and cooperation
among staff
We help on the side of antenatal because there is a
time when women may come to deliver like three
or two a day. And then you find she can’t be here
and there in antenatal .so for us we help her there.
Opened doors for other opportunities for “because if it was not you people our deliveries
funding
would be really down and we were not going to
score anything so I believe it is you who have made
us score so that our graph is high”
Training
Interviewer: According to you what new things
would you say that you have learnt?
Interviewee: New born care including the mothers.
Interviewer: Where did you learn that from?
Interviewee: In the workshop
Perspective of clients about health
workers
Health workers were more
available
“ These days nurses attend to mothers even at night
....... Sometime ago ....nurses would remain indoors
without coming out to help the mothers”
Health workers are more responsive “Ever since the project started they respond very fast and
keep on checking on you”
Attitudes of health workers have
improved
“The coming of the project helped us so much to
improve on the health workers’ attitudes towards the
patients; they no longer shout at us and they give us
good care”
Improved client community
relationships
“We had no love for a hospital because of the nurses; we
used to change from hospital to hospital, but ever since
Results
EXPENDITURE OF FUNDS RECEIVED BY THE HEALTH FACILITIES
INFRASTRUCTURE
23%
DRUGS/SUNDRIES
PERSONNEL
13%
61%
EQUIPMENT
3%
Financial incentives
• Financial incentives very important when salary is
very low
• Conflicts were minimized by
 Discussing procedures with district management
 Asking facilities to meet and agree on how to
spend the money
 Getting feedback and reviewing procedures and
amounts for payment
 Inclusion of all health workers in facility
Challenges
• One of the challenges reported was a high
workload especially in understaffed facilities
• Lack of basic infrastructure such as wards for
admission, ambulances, facilities for record
keeping
• Sustainability of such positive initiatives
“When the project was still going on, the nurse
was ever available but these days, she first digs;
she doesn’t mind at all, so we request the project
to come back and we get good services”
Discussion
• Financial and non financial incentives together with
their internal drive to serve patients had a positive
influence on the behaviour of the health workers
 Health workers not inherently rude but working in
difficult circumstances
 Absenteeism linked to need to supplement salary,
redundancy, poor working conditions
 Use of existing systems / structures for reporting imp
for reducing burden on health workers
 Limited use of non financial incentives at facility level
Policy implications
• Governments need to have comprehensive plans for providing resources
for the delivery of MCH services.
• Negotiation with donors to promote planned targeted use of resources
rather than a project approach but results and accountability must be
strengthened!
 Human resources development - hands on workshops, facility level
supervision and mentoring, problem solving techniques
 Human resources numbers – intergration and team work, recruitment ,
training of middle level providers
 Increased remuneration - Salary with additional amounts linked to
performance ( incentives for improving efficiency and quality )
 Basic Infrastructure -wards, ambulances, lighting
Governments must invest in their human
resources for health for sustained
improvements in the performance of health
workers
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