18 September 2010

Unnecessary Facades

Last week, I was in Uganda to write a story about voucher programs. In development policy circles, vouchers are all the rage. The idea is simple: Vouchers are distributed to patients, either for free or a small fee, entitling them to certain services at accredited facilities (in the case of Uganda, services for pregnant women and for the diagnosis and treatment of STIs). Health care providers are reimbursed for the cost of provision, plus a reasonable profit, after delivery has been verified.

As always, I arrived with a pile of reports in my suitcase. Their uniformity was striking: voucher schemes, they say, Empower Patients to choose where to access health services and Spur Competition among health care providers, who must entice these free-to-choose patients to their facilities.

I’d never been to Uganda before. Got the 10:05 p.m. flight out of Nairobi and landed in Entebbe after eleven. As with all late night arrivals, I felt a tired, jittery vitality, like an insomniac. Peering out the car window, my face pressed up against the glass, I strained to see out into the dark.


The next morning, a team assembled in the vacant lobby of a hotel in Mbabara: two program managers; a donor representative; and me, the analyst. We drove all morning to reach the facility, strangers, trapped in a car together for hours. At first we talked about the program, our professional backgrounds, where we come from. After an hour, the conversation waned. Turned on the radio. A preacher was talking about sin and redemption.

We stared out the windows, lost in our own thoughts, watching the fields whip by, banana trees, ant mounds, men pushing bicycles weighed down with charcoal, and others laying gravel where a new road is being built.

Arrived at the health center midday stiff and a drowsy. Shook hands with Martin, the young facility manager, who was dressed in his finest suit and polished loafers. We were wearing “field” clothes—jeans, tennis shoes.

Inside his spare concrete office, Martin said he’s worried about the women who come for antenatal visits but don’t come back for the delivery. Others refuse to be referred to higher-level facilities, even when they have life-threatening complications.

Why would they do this?

They want to be comfortable, he said. They are used to the traditional birth attendants in the village. And with referrals, some are afraid of being cut open and operated on in a strange, foreign place, and who can blame them?

Even when they want to be referred, there is no ambulance, and the rocky dirt road we traveled down for an hour in Landrovers to reach the facility is difficult to traverse. The nearest health clinic is nearly 20 kilometers away.


At another medical center, I meet four women sitting in a row on a wooden bench in the shade, each in the final stretches of pregnancy. The facility manager is encouraging: ask them questions, he says. There are four of us standing in the sun in front of them, notepads and pens in our hands. I shift uncomfortably from one foot to the other. How many babies do you have, I ask? From where did you come?

Their voices are as soft as feathers, and they bow their heads as if in prayer as they speak. I have three babies, one says. I have five, says another. I have come from 7 kilometers away. I have come from further. There is no where else to go.

At another facility, another manager takes a delegation of six of us on a tour. This is the reception, he says, the lab, the children’s ward. Then he takes us into the labor ward, guides us around a corner and proudly points to a woman with bare legs in stirrups, who is heaving, moaning, about to have her baby.

When we wonder why patients sometimes do not return to the facility to deliver when they could do so for free; when we think it is illogical to forfeit the opportunity to come to a clean, safe clinic—to sacrifice so much by not returning—maybe the patients are thinking of all they sacrifice when they do.


Kenya also has a voucher scheme, and one afternoon I visited some accredited facilities in the Nairobi slum of Korogocho. There were three of them, close to each other. I could walk between them easily.

I asked the facility managers how they would compete with the other facilities to lure patients? They downplayed the idea: we work together, they said, we don’t compete.

But you are making improvements to attract patients, aren’t you?

They said they improve their facilities first, because they are strongly encouraged to do so by the agency managing the program, and second, as a way to ensure they will be left with something when donor funds for the program run out. Facility managers in Uganda say the same thing, and for them, the latter reason is even more pressing, since donor funds for the three-year program are spent, and come next year, their new patients and income may disappear.


We give names to what our programs do for patients. Empower. Catalyze. Choice. But assessing their views, their motives, and the effect we have on them, is more difficult than is generally assumed.

Maybe vouchers empower women. Maybe they don’t. Maybe instead they are a simple subsidy for particular services at particular locations. And maybe facilities aren't upgrading infrastructure and hiring new staff out of a sense of competition.

But what is wrong with this? Patients are still coming to facilities, where the safe delivery of their babies can be nearly guaranteed. And facilities are making improvements, which make them more comfortable and responsive to patients. Moreover, these programs serve as models for governments considering health insurance programs for the poor (which both Kenya and Uganda are) but are concerned about the mechanics of accreditation and reimbursement.

Plenty of thoughtful people have questions and concerns about vouchers—about the cost and complexity of administering them versus other mechanisms to increase access; about preventing fraud and monitoring facility quality, among other things. But overall, these programs are a good thing.

Why isn’t the way things really are enough?

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