This article is part of the supplement: An innovative approach to building capacity at an African university to improve health outcomes

Open Access Research

Increasing access to institutional deliveries using demand and supply side incentives: early results from a quasi-experimental study

Elizabeth Ekirapa-Kiracho1*, Peter Waiswa1, M Hafizur Rahman2, Fred Makumbi1, Noah Kiwanuka1, Olico Okui1, Elizeus Rutebemberwa1, John Bua1, Aloysius Mutebi1, Gorette Nalwadda3, David Serwadda1, George W Pariyo1 and David H Peters2

Author Affiliations

1 Department of Health Policy, Planning and Management, School of Public Health, Makerere University College of Health Sciences P.O.Box 7072, Kampala, Uganda

2 Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA

3 Department of Nursing,School of Health Sciences, Makerere University College of Health Sciences, P.O.Box 7072, Kampala, Uganda

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BMC International Health and Human Rights 2011, 11(Suppl 1):S11  doi:10.1186/1472-698X-11-S1-S11

Published: 9 March 2011



Geographical inaccessibility, lack of transport, and financial burdens are some of the demand side constraints to maternal health services in Uganda, while supply side problems include poor quality services related to unmotivated health workers and inadequate supplies. Most public health interventions in Uganda have addressed only selected supply side issues, and universities have focused their efforts on providing maternal services at tertiary hospitals. To demonstrate how reforms at Makerere University College of Health Sciences (MakCHS) can lead to making systemic changes that can improve maternal health services, a demand and supply side strategy was developed by working with local communities and national stakeholders.


This quasi-experimental trial is conducted in two districts in Eastern Uganda. The supply side component includes health worker refresher training and additions of minimal drugs and supplies, whereas the demand side component involves vouchers given to pregnant women for motorcycle transport and the payment to service providers for antenatal, delivery, and postnatal care. The trial is ongoing, but early analysis from routine health information systems on the number of services used is presented.


Motorcyclists in the community organized themselves to accept vouchers in exchange for transport for antenatal care, deliveries and postnatal care, and have become actively involved in ensuring that women obtain care. Increases in antenatal, delivery, and postnatal care were demonstrated, with the number of safe deliveries in the intervention area immediately jumping from <200 deliveries/month to over 500 deliveries/month in the intervention arm. Voucher revenues have been used to obtain needed supplies to improve quality and to pay health workers, ensuring their availability at a time when workloads are increasing.


Transport and service vouchers appear to be a viable strategy for rapidly increasing maternal care. MakCHS can design strategies together with stakeholders using a learning-by-doing approach to take advantage of community resources.