A Fruitful Marriage: Urban Voucher System Reduces Maternal Deaths in Harare’s Central Hospitals/Council Clinics

Like many women in high-density and peri-urban communities, Method Pagiwa (26), from Kuwadzana Phase in Harare, registered her pregnancy with the Antenatal Clinic at Rujeko Polyclinic in Dzivarasekwa, when she was seven months into her pregnancy. This, according to the World Health Organisation (WHO) standards is not recommended as they prescribe that women in developing countries such as Zimbabwe, should seek ANC within four months (17 Weeks) of pregnancy.

By Michael Gwarisa

On July 7, 2023, Method started experiencing labor pains and her waters broke while she was on her way to the clinic. Upon arrival at Rujeko Clinic, and after the nurses had examined her, she was told that her baby had pooped in the womb and she needed hospital and specialist attention.

Within a short space of time, I saw an Ambulance arriving to ferry me to Perirenyatwa Hospital. In my head I was now wondering who had called the ambulance and how I was going to pay for the Ambulance fee as well as for the hospital and operation bills,” said Method.

Since Method was only two months into the Urban Voucher initiative being implemented by Cordaid and the Ministry of Health and Child Care through support from the World Bank (WB), she wasn’t very much aware of some of the perks and advantages that come with the program until the day of her delivery.

“I was admitted at Parirenyatwa Hospital and they conducted a scan which revealed that the baby had pooped in the womb two weeks ago. I was immediately booked for a Caesarean Section at Mbuya Nehanda Maternity ward here at Parirenyatwa. I was operated on and now I have this bouncing baby girl in my arms. All this I received for free curtsy of the Urban Voucher program.”

Thousands of women have benefited from the Urban Voucher (UV) system which is currently being implemented in two major cities of Harare and Bulawayo. The program works with social workers and rewards relief to the utilizers of the facilities, by paying on their behalf. The UV promotes institutional deliveries as well as providing free services on the other hand providing a cost recovery to the facility. It pays for user fees and is for urban settings.

In Harare, Parirenyatwa Group of Hospitals acts as a referral point for all cases that would have been referred by all local clinics under the RBF Voucher System in Harare. Mbuya Nehanda, the Maternity division of Parirenaytwa Hospitals enrolled under the Urban Voucher system in 2021 and they started receiving patients with vouchers around January 2022.

Sister Bernadette Mandaza, the Senior Nursing Officer at Mbuya Nehanda Maternity Hospital 
said they have served 2,900 women since 2022 under the RBF Urban Voucher program.

“These are the women we have delivered and received either as referral cases or some who just come under the RBF Voucher system here at Parirenaytwa. We see patients who are referred from local city council clinics. Most of them are referred to with compilations. We also see those who just wish to come and be treated at Parirenyatwa,” said Sister Mandaza.

Sister B Mandaza chats to Method who has delivered her baby. Method was referred from Ruveneko Clinic in Dzivarasekwa

She said the patients who are on the Urban Voucher are usually maternity cases and they offer complicated antenatal services and complicated deliveries such as breached deliveries and Caesarean Sections as well as complicated post-natal complications.

“These include post-partum hemorrhage from the clinic, we also have premature babies referred to Parirenyantwa, Mbuya Nehanda.”

Parirenyatwa Hospital has received subsidies from the Urban Voucher program and they have managed to buy some medicines, surgical sundries, and some equipment. They have also brought a refrigerator and a microwave to put foodstuffs and warm for their employees to motivate them. The RBF Urban Voucher initiative is part of the Health Sector Development Additional Financing V, which is Co-financed by the Government of Zimbabwe and the World Bank, while the Ministry of Health and Child Care and Cordaid are the implementing partners.

Pregnant women under the Urban Voucher system from various communities in Harare come for ANC registration at  Mbare Poly clinic

In Harare, one of the clinics benefit from the Voucher system, Mbare Polyclinic, also known as Edith Opperman has gone for two consecutive years without recording any maternal death at the back of an Urban Voucher program that has greatly improved the quality of care at the facility. The Urban Voucher system was adopted at Mbare Polyclinic in 2013.

Christopher Gumunyu, Nurse in Charge, Mbare Polyclinic said the Urban Voucher system has greatly reduced home births and complications related to delayed access to services.

“When the Urban Voucher came to Mbare community, before, a lot of women were delivering at home. We are now delivering the majority at the facility. There is a reduction in home deliveries, there is also a reduction in babies who are being born before their time arrives. There is also a great reduction in maternal deaths. At our facility for the past two years, we have had none.

“So it’s a plus because we have been able to identify impending complications beforehand and clients being referred for further management in time which is a thing that could not be done before the introduction of the Voucher system where people could deliver at home or be delivered by traditional births attendant, having complications and succumbing during the birth processes at times,” said Gumunyu.

The Urban Voucher system has also come through to assist the staff through motivating the staff through incentivising the staff in the midst of massive health workforce attrition.

The UV was adopted after advocacy through the MoHCC who could not pay user fees for the ANC Bookings. When they were identified. Cordaid came in and they started to screen the community to identify women who could pay user fees for themselves. When they were identified, Cordaid chose community members who identified those that had a need to put in the program.

They would write a voucher for the identified client after viewing their poverty data through a tool they use to assess the poverty level of a client in the community. When they visit the clinics, they produce a voucher for ANC booking. Cordaid pays for the user fees through the voucher system. The Voucher pays for the ANC, labour, delivery, and any transfers should there be any need to the central hospitals. The same voucher when they get to the central hospitals is used as a mode of payment and pays for all services required.

Some of the successes of the Urban Voucher system in Harare include improving access to maternity services – maternity services in Harare are free for all the poor, efficient screening of the urban poor – from DSS to DHCS to community screening, improved quality of care in clinics implementing the program – quality supervision by the DHE and CHE, motivating of staff through incentives – 50% earnings shared by staff. The Voucher system has improved the  governance and Leadership at the clinic level, autonomy, community participation, improved Linkage between the institutions and community through Health Centre  Committee (HCC) engagement and health facilities improved/ renovated.

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