Community willingness to pay for maternal transport in Kabarole District, Western Uganda: A cross-sectional study

Andrew Kuguminkiriza Tusubira^1,&, Christine Muhumuza², Aloysius Mutebi¹, Nathan Ruhinda¹, Doreen Tuhebwe¹, Michael Ediau¹, Angela Nakanwagi Kisakye¹, Freddie Ssengooba¹, Sebastian Olikira Baine¹

 

¹Department of Health Policy, Planning and Management, Makerere University College of Health Sciences, School of Public Health, P.O Box 7072, Kampala, Uganda, ²Department of Epidemiology and Biostatistics, Makerere University College of Health Sciences, School of Public Health, P.O Box 7072, Kampala, Uganda

 

 

^&Corresponding author
Andrew Kuguminkiriza Tusubira, Department of Health Policy, Planning and Management, Makerere University College of Health Sciences School of Public Health, P.O Box 7072, Kampala, Uganda. tusumose@gmail.com

 

 

 

 

Maternal health is one of the major global health challenges [1,2]. In 2017, about 810 women died every day from preventable causes related to pregnancy and childbirth [2]. Although some countries have made remarkable progress, most deaths, (94%), still occurred in low and middle income countries, with sub-Saharan Africa accounting for nearly two-thirds of the maternal deaths [3]. Pregnancy complications are often unpredicatable and delays in obtainig appropriate care greatly contribute to the poor pregnancy outcomes[4]. Thaddeus & Maine [5], distinguished the three major delays that affect pregnancy and childbirth outcomes. These include delay in: deciding to seek appropriate medical care; reaching an appropriate obstetric facility; and receiving adequate care when a facility is reached. The second delay is a direct consequence of transportation systems that are either expensive, poor, non-existent or a combination of factors[6]. Studies in rural Gambia, Kenya, and Uganda indicate that pregnant women experience transport related delays including geographical inaccessibility and lack of money to pay for transport to health facilities [6,7].

 

The significance of efficient transportation in obstetric care is related to the unpredictability of pregnancy complications and the potential of such a complication to become severe and life threatening [8]. However, effective maternal transport services have financial implications. Costs must be incurred by the pregnant mother, her male partner, or a concerned entity. It is estimated that less than one percent of the population in low-income countries has access to conventional emergency transport, such as an ambulance. Walking remains a primary mode of transportation for pregnant women thereby severely limiting their ability to reach appropriate healthcare [9]. Therefore most households in resource-limited settings rely on public transportation including hired or shared cars, animal drawn carts, and recently the intervention of project funded transportation for transferring women to health facilities [10,11]. Project funded transport services mainly depend on donor funds and may not be sustained when external support dwindles or ends due to constrained health sector budgets especially in low income countries [12,13].

 

In Uganda, projects which offer financial assistance for the transportation of pregnant women to access antenatal, delivery, and postpartum care services have been implemented [14,15]. Most of the transport services depend on donor funds, which may not guarantee sustainability of the transport services when the funding ends. In Kabarole district, Western Uganda, a development partner funded a project which facilitated maternal referral transportation through motorized ambulance services and establishment of a vouchers system for the use of commercial motorcycle riders by pregnant women [14]. It is not clear what will happen to the sustainability of the transport services when the development partner funding winds up. Either the government or community may have to raise funds for sustainability.

 

The World Health Organization has urged member states to introduce health-financing systems or develop prepayment for the health sector through financial contributions, with a view to sharing risk among the population and avoiding catastrophic healthcare expenditure and impoverishment of individuals as a result of seeking care[16]. Well-organized and sustained community based payment arrangements have the potential of developing into strong and acceptable mechanisms to contribute to the sustainability of health interventions [17]. However, no documentation exists on whether community financing can be embraced to sustain maternal transportation services. We therefore assessed community willingness to pay for maternal transport services and associated factors in Kabarole district, Uganda.

 

 

Study setting

 

We conducted this study in Kabarole district located in Western Uganda. Kabarole is one of the districts in Uganda where maternal transport services have been facilitated by the Saving Mothers Giving Life (SMGL) project [14]. The project´s approaches focused on equipping facilities, improving the supply system and strengthening linkages between communities and facilities through a facilitated transportation system. This has led to a decrease in maternal mortality by 45% since 2012 in these districts [18]. This winding - up project has been funding and functionalizing the maternal transport services in Kabarole district through provision of motor vehicle and motorcycle ambulances, and vouchers to subsidize private transportation by motorcycles since 2012. Mothers are transported from their homes to the health facilities using motorcycles and their riders are given vouchers to claim payments[14].

 

Study design

 

We conducted a cross sectional study, between June and August 2015, using quantitative data collection methods.

 

Study Population

 

We interviewed adult household heads in Kabarole district. A household was defined as a group of people who stay together and commonly share a meal. A household head was an individual in the family who had authority to exercise family control and offered support to the dependent members in a household.

 

We included household heads who were residents of the selected sites and excluded those who had a health condition that would hinder them from providing information.

 

Sample size

 

The sample size was estimated using the Leslie Kish formula[19]. The estimated proportion of community members willing to pay for services was 30% [20], we added a design effect of 2 [21] (to cater for clustering of individuals), the total sample size was 646.

 

Sample selection

 

Using simple random sampling (SRS), one county (Burahya county) was selected from the rural counties while Fort Portal Municipality was purposively selected. The equivalent of one sub-county was selected from each of the two counties thus, Bukuku sub-county from Burahya county and West Division from the municipality. Using simple random sampling, we randomly selected three villages from each sub-county while using a list with all the villages. In each selected village, we used a household list, updated by Village Health Teams (VHTs), to identify households. This was our sampling frame for the households to be selected. We used proportionate to size sampling to determine the number of households selected per village. For each selected household, we purposively selected the household head. In case the head was not present, at least two re-calls would be made before selection of another household.

 

Study variables and measurements

 

The primary outcome variable was “willingness to pay” defined as a household head who was willing to contribute to the maternal transport services in the district. It was a binary outcome, whether the respondent was “willing to pay” or “not willing” and measured as a proportion of those willing to pay for maternal transport services. Those willing to pay were asked for preferred payment amounts. We also obtained information on preferred entity to coordinate and manage the funds, the preferred transport means and payment mode.

 

The independent variables were classified into socio-demographic factors, community factors, and Perceptions about community funded maternal transport. Socio-demographic factors included; age, marital status, sex, level of education and religion. To classify socio-economic status (SES), principal components analysis (PCA) was done on 7 household assets: 1) a mobile phone, 2) a bicycle, 3) a radio, 4) a television, 5) a motorcycle, 6) a motor vehicle and 7) land. These items were used in the Uganda Demographic and Health Survey [22] to determine wealth index which is a good proxy for measuring wealth of households. The component on which most items loaded was used to generate a socio-economic status score for each respondent. Respondents´ socio-economic status scores were then grouped into three-quantiles of socio-economic status. Other two covariates included: 1) distance from health center (categorized into: health facility within a radius of five kilometers and health facility in more than five kilometers); and 2) preferred place of birth delivery sought (whether health facility or traditional birth attendants (TBAs)).

 

Data collection

 

We used structured questionnaires designed using variables from previously conducted study tools on willingness to pay [23-25]. The tools were pretested in Kibiito town council, a similar population outside the study area before the actual field study. Data were collected using face-to-face interviews by ten research assistants who had attained at least a diploma and could comprehend both English and Rutoro, the local language. Research assistants were supervised by the Principal Investigator during the data collection exercise. Collected data were entered, edited and cleaned using Epi info prior to analysis using Stata version 13.

 

Data analysis

 

At univariate analysis level, we obtained frequencies and proportions to describe the study population and also obtained the proportion of willingness to pay. We estimated bivariate and multivariable modified Poisson regression models to establish association between dependent variable (WTP) and the independent variables. We estimated bivariate modified Poisson regression models to obtain prevalence ratios (PR) with 95% confidence intervals. We used prevalence ratios rather than odds ratios as the measure of association because the outcome (WTP) was highly prevalent at 68.4%. In such scenarios, when the outcome is highly prevalent, odds ratios tend to overestimate the strength of association [26,27].

 

Prevalence ratios were estimated using the Modified Poisson regression analysis model via generalized linear models with family (Poisson), link (log) and with robust standard errors [28]. We then estimated a multivariable regression model to determine adjusted prevalence ratios of factors associated with willingness to pay. We obtained the independent effects for willingness to pay after running the final model. The factors adjusted for included; age, sex, place of residence, education level, marital status, occupation, participation in a saving scheme, household wealth index, distance to health facility, perceived quality of health care and perceived ability to pay. Variables in the model were eliminated if they were not consistently significant in further multivariable analysis. The goodness of fit checks and likelihood ratio tests were conducted to select the final model with adjusted estimates. Adjusted prevalence ratios with 95% confidence intervals and P-value less than 0.05 were considered statistically significant. All analysis was conducted using Stata version 13.

 

Ethics approval and consent to participate

 

This study was approved by Makerere University school of Public Health Higher Degrees Research and Ethics Committee (HDREC). Since this work was part of the field research studies done in fulfillment of a master´s degree, ethical approval was provided by HDREC on behalf of the Uganda National Council for Science and Technology (UNCST). Further permission to conduct the study was sought from the District Health office of Kabarole District and from the local council leaders. Written informed consent was obtained from participating household heads and they signed to confirm consent. Filled questionnaires were kept safe to ensure confidentiality of all the information obtained.

 

 

Socio-demographic characteristics of study respondents

 

We found that respondents´ mean age was 33.8 years (standard deviation +/-8.85). Majority of the respondents 489/646 (75.7%) were male and 51.7% were residents in rural settings. The largest proportion of respondents had attained primary education 341/646 (52.8%), 63.3% were in a marital union, more than half (53.4%), were farmers and 396 (61.3%) were in the lowest quantile of wealth index Table 1.

 

Willingness to pay for maternal transport services in Kabarole district

 

Out of the 646 respondents, 442 (68.42%) were willing to pay for the maternal transport services in the district. Half of those willing to pay 221/442 (50%) were farmers, 217/442 (49.10%) were residents in rural settings and most, 291/442 (65.84%), were married.

 

Preferences by respondents willing to pay for the maternal transport services

 

In terms, of the 442 respondents willing to pay, most, (65.38%), preferred monthly payment with an average amount of UGX 2,207.6/= (<1.00 USD); 55 (12.44%) preferred bi-annual payment with an average amount of UGX 6,581.8/= (2.0 USD); and 98 (22.17%) preferred an annual payment with an average amount of UGX 11,418.3/= (3.5 USD). More than half, 53.39% (236/442) preferred a Non-Government Organization (NGO) while 32.13% (142/442) preferred the Government to manage the funds. Majority 71.71% (317/442) preferred the management of funds to be done at sub- county level and most 61.54% (272/442) were willing to pay for motor vehicle ambulances Table 2.

 

Factors associated with willingness to pay for maternal transport services

 

Table 3 shows the bivariate association between willingness to pay and respondents´ background characteristics. Even though 50.90% of the respondents willing to pay were from urban settings, place of residence had no statistical significance with willingness to pay (PR 1.11 95% CI 0.99 - 1.23). Thus, in both setting (i.e., rural or urban), the largest proportion were willing to pay. Having attained any level of education was significantly associated with willingness to pay at bivariate level (P-value < 0.001). Though most of the respondents willing to pay were between 25 and 35 years of age (46.38%), age was not statistically associated with willingness to pay. Similarly, religion, occupation, and marital status were not statistically associated with willingness to pay.

 

In the adjusted model, those who had ever attained any level of education, primary (APR 1.35, 95% CI 1.10-1.66), secondary (APR 1.34, 95% CI 1.07 - 1.68) and tertiary (APR 1.56, 95% CI 1.20 - 2.03) education were more willing to pay for the transport services compared to those who had never attained any education. Being married (APR 1.16, 95% CI 1.03 - 1.32), having ever participated in a saving scheme (APR 1.13, 95% CI 1.01 - 1.26) and having a health facility at a distance of more than five kilometers (APR 1.28, 95% CI 1.11 - 1.46) were positively associated with willingness to pay. Other factors such as age, sex, place of residence, occupation, and wealth index (social economic status) were not significantly associated with willingness to pay in the final model Table 4.

 

 

We found that majority (68%) of the respondents in both rural and urban communities were willing to pay for maternal transport. Most participants preferred monthly payment, a NGO to manage the funds and payment mainly for the motor vehicle ambulances. Being educated, married, participating in a saving scheme and staying more than five kilometers away from a heath facility were positively associated with WTP. This result is in line with similar study findings on willingness to pay for maternal health care where most of the respondents were willing to pay [29,30].

 

Even when stratified by sex (i.e., male or female) and residence (urban or rural), majority in each stratum were willing to pay for the maternal transport services. This was contrary to findings by two studies in Nigeria [17,31], which reported that the place of residence had influence on peoples´ willingness to pay. The high response to willingness to pay could be attributed to the benefits and the impact of the Saving Mothers Giving Life project in the district as noted by the evaluation reports [14,32].

 

Most respondents in this study preferred monthly payment at an average amount of Ugandan Shillings (UGX 2207.6) (< 1.0 USD). Studies on willingness to pay for maternal health in low- and middle-income countries have mainly reported monthly payment modality as a payment preference [29,33]. This study adds to the existing literature that monthly payment modality was also preferred for transport services. We however would like to note that the average amount suggested by respondents in this study is lower than what is reported in these studies. The low amount could also be because most respondents were in the lower social economic status category of the wealth index and majority of those willing to pay were subsistence farmers who could be low-income earners. Still in line with preferences, our study shows that more than half of those willing to pay preferred a Non-Governmental organization to manage the contributed funds. This could be because it has been a Non-Governmental organization running the operations of the saving mothers giving life project [14].

 

Our study results show that being married was positively associated with willingness to pay. This is consistent with previous studies on willingness to pay [34-36] . A study in Nigeria reported that marital status was found to increase willingness to pay by 51% [34]. Marital status has been shown to influence positive behavior towards health services [37] including easy mobilization of resources [20]. Their positivity towards payment probably shows that they are more likely to have children, hence an anticipated need of transport services.

 

Being educated was associated with a persons´ willingness to pay for the transport services in the district. This is in line with several studies on willingness to pay for health care [38-41]. The influence of education on WTP could be through increase in positive attitudes which enhances acceptance as noted by Worasathit et al.,[42]. Similarly, those who had ever participated in a saving scheme were more willing to pay for the maternal transport services. This result is consistent with the finding in a Nigerian study where membership to a savings and loan group was a predicted willingness to pay for maternal services [43]. This could be due to the fact that, those who have participated in saving and loan group schemes are aware of the need for protection against financial risks during health emergencies.

 

Geographical location from a health facility has been identified as one of the determinants of willingness to pay for health care [34,39,44,45]. In this study, residing more than five kilometers from a health facility was associated with willingness to pay for the transport services. This was consistent with studies done in rural Nigeria [46,47] and Burkina Faso [44] which reported that households that had to travel longer distances to access health care were more willing to pay than those that had to travel lesser distances. This could be because individuals are often willing to pay when they are certain that an intervention will improve their access and quality of health care [48]. This finding is likely to vary in a situation where public transport systems like “taxis” or “boda bodas” are readily available or not.

 

The following limitations should be considered while interpreting the results. Though we did not obtain information about having plans for childbirth or being pregnant to grasp the intention for future use of these services, information on being married was proximate to this context. Besides, further research can be done to understand childbearing plans and willingness to pay for maternal transport services. This study was done among a population, which had functional maternal transport services. Therefore, the findings may not be generalizable to communities that have not yet experienced referral transport services at a localized level.

 

 

Most of the respondents were willing to make a monthly contribution towards the maternal transport services in Kabarole district. Majority preferred management of funds to be at sub- county level and motor vehicle ambulance was the most preferred means of transport. Having attained education, being married, ever participated in a saving scheme and having a health facility at a distance of more than five kilometers were positively associated with willingness to pay. There is need to embrace this positive response towards WTP and consider the possibility of community contribution to maternal transport services. A scheme geared towards monthly contribution can be established in the district to enhance saving for maternal transport services. Sensitization on importance of community contribution to maternal transport will also be crucial.

 

 

The authors declare no competing interests.

 

Funding

 

This study was funded by Makerere University School of Public Health through Cooperative Agreement Number: 5U2GGH000817-03 ("Provision of Comprehensive HIV/AIDS services and developing national capacity to manage HIV/AIDS Programs in Uganda") from the US-Centers for Disease Control and Prevention. The African Field Epidemiology Network (AFENET) funded the scientific writing workshop that led to the production of a complete draft of this manuscript.

 

 

AKT conceived and led the design of the study protocol, data collection, data analysis and initial interpretation of data. He wrote the first draft of the paper and revised the paper for substantial intellectual content. He was also responsible for submission of the paper. SOB, CM, and AM, made substantial contributions to the design of the study, worked on data interpretations and were involved in the drafting of manuscript. They revised the paper for important intellectual content. NR, DT, ME made substantial contributions to the conception and design of the study. They contributed to the data collection process, data interpretation and reviewed the manuscript drafts for important intellectual content. FS made substantial contributions to the conception and design of the study. He contributed to the interpretation of data and revision of the manuscript drafts. He revised the paper for important intellectual content. ANK reviewed the final drafts of the manuscript. All authors read and approved the final version.

 

 

The authors acknowledge the Makerere University School of Public Health Resident Mentors and staff who provided technical guidance, follow-up and support throughout the process. We thank the administration of Kabalore district and the District Health Team for supporting the team during data collection. We acknowledge all the study participants and the research assistants for their invaluable contributions.

 

 

Table 1: Demographic characteristics of the study participants

Table 2: Preferences by the respondents willing to pay for maternal transport services in Kabarole District, Western Uganda

Table 3: Bivariate association between willingness to pay and demographic characteristics

Table 4: Adjusted factors associated with willingness to pay for maternal transport services in Kabarole District, Western Uganda

 

 

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