The first time I met Shoktambe, she was sitting outside her mud and straw hut in the midst of the banana plantation where she works. She told me how she had lost three babies after delivering at home without any trained assistance. As she spoke, she held a bundle; a tiny healthy baby born a few weeks earlier in a small but local private clinic she was able to access with a HealthyBaby voucher.
The HealthyBaby scheme was set up in 2006 and aims to facilitate the safe delivery of 60,000 babies by the end of the project in July 2011. Vouchers are sold to women considered most in need, such as Shoktambe. She first heard about the vouchers on the radio and decided to buy one when a vendor from her community came around, explaining that it cost 3,000 shillings (about US$1.2 ) and entitled her to: four antenatal checks; malaria treatment; safe delivery of her baby; free referral to a hospital in the event of a complication during delivery; and a postnatal check. Earning about US$1 per day, Shoktambe had saved up enough to buy the voucher within a week.
I asked Shoktambe why she had not visited a public hospital for any of her last four pregnancies given that user fees had been removed in Uganda. There was quiet anger in her answer. “I visited the hospital once. They told me they didn’t want to touch me because I wasn’t clean.” And Shoktambe went on to explain that she would have also been required to purchase the equipment and medicines needed to treat her – a cost well beyond her means. She gave the impression that walking the ten miles to this hospital while pregnant had never been in serious contention. But would she use the voucher if pregnant again? “Yes, it is not expensive.”
I left Shoktambe and went on to meet some local private healthcare providers in the same district. The first of these was Asaf, the clinical officer who had been reimbursed for delivering Shoktambe’s baby - his clinic being a 20 minutes walk from her home - after processing her HealthyBaby voucher with Marie Stopes Uganda.
Asaf showed me around his small but spotless clinic and explained that, unlike many of his fellow clinical graduates, he had chosen to remain in a rural area in favour of the city in order to help a community with very limited access healthcare. He told me about a woman who had, in desperation, put her life at risk when she began to haemorrhage by using some rags to stem the bleeding. She turned up to Asaf’s clinic in the middle of the night. He explained how he could never turn anyone in that condition away, regardless of whether they could pay him or not, but that in providing free treatment he was compromising his ability to pay his staff and purchase more medicines. By qualifying for the voucher scheme, he had gained the freedom to serve many low-income clients without fear of financial ruin.
Talking to Shoktambe, Asaf and the District Health Officer had made it very clear to me how vouchers have the potential to join up public health authorities with private providers and bring subsidised or free services to underserved women.