Evaluation of The Output Based Approach in Uganda: Impact of Contracted Facilities and Social Marketed Vouchers On Knowledge, Utilization, and Prevalence of Sexually Transmitted Infections 2006-07

EVALUATION OF OUTPUT-BASED AID (OBA) IN
UGANDA:
IMPACT OF CONTRACTED FACILITIES AND SOCIAL

MARKETED VOUCHERS ON KNOWLEDGE, UTILIZATION AND
PREVALENCE OF
SEXUALLY TRANSMITTED INFECTIONS (STIs) 2006-2007
Bushenyi, Ibanda, Isingiro, Kiruhura, and Mbarara Districts
OCTOBER 2008
Output-based Aid Uganda – Follow-up Survey Report 1

THIS STUDY WAS UNDERTAKEN WITH GENEROUS SUPPORT FROM
THE KFW DEVELOPMENT BANK WITH
SUPPLEMENTAL SUPPORT OF THE BOREN FELLOWSHIP AND
THE BIXBY PROGRAM IN POPULATION, FAMILY PLANNING, AND
MATERNAL HEALTH AT
THE UNIVERSITY OF CALIFORNIA, BERKELEY

TABLE OF CONTENTS
LIST OF ABBREVIATIONS ................................................................................................... 4

EXECUTIVE SUMMARY ....................................................................................................... 5
SECTION I: INTRODUCTION ............................................................................................... 6
SECTION II: KNOWLEDGE OF OBA PROGRAM AND STIs IN 2006 & 2007..................... 10
2.1 How well did respondents know about the voucher? ..................................................... 10
2.2 How well did respondents know about symptoms?........................................................ 11
SECTION III: STI UTILITIZATION IN 2006 AND 2007 ........................................................ 14
3.1 Who reports having STI symptoms?.............................................................................. 14
3.3 How many patients traveled from subcounties without clinics? ...................................... 18
3.4 Poverty rate among voucher patients ............................................................................ 18
3.5 How competitive was voucher utilization? ..................................................................... 19
SECTION IV: PREVALENCE OF SYPHILIS IN 2006 AND 2007 ......................................... 21
CONCLUSION .................................................................................................................... 23
APPENDIX 1: Female Contraceptive Use and Births .......................................................... 24
APPENDIX 2: Spatial implications in clinic utilization........................................................... 29
APPENDIX 3: Data collection methodology......................................................................... 30
APPENDIX 4: Study Design and Cross Over Concerns ...................................................... 39
APPENDIX 5: General Health Care Utilization .................................................................... 42

LIST OF ABBREVIATIO S
GPOBA Global Partnership on Output-based Aid

HHI Herfindahl-Hirschman index
HIV Human immunodeficiency virus
KfW KfW Development Bank
MSI-U Marie Stopes International Uganda
OBA Output-based aid
RPR Rapid plasma reagent
STIs Sexually transmitted infections
TPHA Treponema pallidum hemagglutination assays
UMoH Uganda Ministry of Health
USAID United States Agency for International Development
VDRL Venereal Disease Research Laboratory
VSHD Venture Strategies for Health and Development
VMUS Voucher management unit system
WHO World Health Organization

EXECUTIVE SUMMARY
This report presents the initial findings from an impact evaluation of a results-based health
services program in southwestern Uganda. The output-based aid (OBA) strategy contracts
healthcare facilities to provide specific high-quality services to voucher-bearing patients.
Facilities are reimbursed only after treatment has been verified. Patients, after buying a
highly discounted voucher, are permitted to visit any contracted facility for treatment. This
first OBA program educated the general population on STI risks and symptoms as part of a
large marketing campaign that was rolled out together with the results-based payments for
treatment of sexually transmitted infections. Given the often stigmatized nature of STIs, the
OBA program recognized the importance of investing in an extensive marketing campaign.
This report presents an analysis of the OBA program’s impact on knowledge of sexually
transmitted infection (STI) symptoms, STI treatment utilization, and prevalence of selected
STIs in southwestern Uganda.
Although final program impact will be determined from a paired cross-sectional ‘before and
after with controls’ population survey design, initial findings are reported “before and after”.
The baseline survey took place in July and August 2006 as the program was launched and
the follow-up survey was carried out in October and November 2007. The combination of
both household surveys tested for differences in STI prevalence, utilization of STI treatment
services, and knowledge of STI symptoms. Key findings are summarized here.
KNOWLEDGE
• Between 2006 and 2007, awareness of the STI voucher increased more than 25 percent.
The 2006 baseline household survey found that 24 percent of male respondents and 20
percent of female respondents already had heard of the STI voucher (radio ads preceded
voucher distribution by a month). In the follow-up survey, over 50 percent of respondents
had heard of the STI voucher.
• Of the 1131 respondents in 2007 who gave the correct voucher price, 43 percent reported
having 2 or more STI symptoms in the past 6 months. However, in the group most at need
– those who had a reactive TPHA result – the market penetration was no higher than the
general population. It would be better if messages and marketing media reached a higher
proportion of the type of respondent who had a reactive TPHA result.
• Reliance on radio for health information was very high in both surveys. In 2006 over 65
percent of respondents indicated “radio” as their preferred means to learn about STIs and
in 2007 more than 70 percent named “radio” their preferred source for STI information.
• Recognition of STI symptoms among the general population improved 10 percent between
2006 and 2007. Sixty-nine percent of respondents in 2006 and 79 percent of respondents
in 2007 were able to recognize two or more STI symptoms.
PREVALENCE
• In both survey years, about 40 percent of respondents reported having one or STI
symptoms in the previous six months. Of respondents with one or more STI symptoms,
one-third had two or more sex partners in the same period.
• In both years, the poorest quartile of respondents reported nearly twice the burden of STI
symptoms as the wealthiest quartile. There was no significant change in the frequency of
STI symptoms by wealth quartile in the two surveys.
• Evidence is suggestive but by no means conclusive that syphilis prevalence fell between
baseline and follow-up surveys. Syphilis prevalence, based on TPHA test results alone,

fell six percent between baseline and follow-up surveys. 18 percent of respondents had
reactive results in 2006 and 12 percent in 2007. Syphilis prevalence, based on VDRL lab
results alone, fell two percent between baseline and follow-up surveys. Six percent of
respondents had reactive results in 2006 and 4 percent in 2007. Syphilis prevalence
remained unchanged when TPHA and VDRL results are combined – only 3 percent of
respondents were reactive on both tests in the 2006 and 2007 surveys.
UTILIZATION
• Although the most common reason for not seeking healthcare when reporting a health
complaint was “lack of money” in both years, 10 percent fewer women cited “lack of
money” in the 2007 survey. The second most common reason for not seeking healthcare
both years was “distance to provider”.
• In both years, more than 50 percent reported using private facilities for STI treatment.
• Among both men and women reporting STI symptoms, utilization of STI treatment
remained constant between baseline and follow-up surveys even though significantly fewer
respondents reported having two or more STI symptoms in the follow-up survey.
PROGRAM PERFORMANCE
• More than 40 percent of voucher-bearing patients treated between July 2006 and April
2008 came from subcounties with poverty rates above 35 percent.
• The percent of households living in poverty ranged from less than 10 percent to more than
40 percent in the subcounties where voucher patients reside. The subcounty poverty rate
had a significant inverse correlation (r= -0.44, p< 0.001) with whether the subcounty had a
contracted clinic.
• When the distribution of vouchers hit a high of more than 2500 vouchers in August 2007,
the measure of monthly market concentration among clinics – Herfindahl-Hirschman index
(HHI) – fell to its lowest value in 2007. Competition in this small but growing healthcare
voucher market is affected as much by management agency’s consistent supply of
vouchers as it is by patient demand.
The first section provides background. The second, third and fourth sections present findings
from the 2006 and 2007 surveys. The follow-up survey found an increase in knowledge but
little change in utilization for the general population. A 2007 clinic evaluation, relying on
clinic records, indicated a dramatic increase in utilization in first of OBA compared to the
year prior (Lowe, Bellows 2007). Syphilis prevalence was lower in the follow-up survey than
the baseline survey, but one should be very careful inferring causation given the study
design. To be causally plausible, the effect of contracting facilities and targeting vouchers
would have affected the quality of treatment and the numbers seeking STI care. This
evaluation presents evidence that the Uganda OBA program increased knowledge of STIs,
may have improved utilization at contracted facilities and is associated with declines in some
measures of syphilis prevalence.
SECTIO I: I TRODUCTIO
The Uganda OBA program began distributing vouchers in July 2006. The Ministry of Health
contracted Venture Strategies for Health and Development to conduct an evaluation of the
output-based aid (OBA) project. The objective of the impact evaluation is to determine
whether there were detectable changes in general population attitudes, healthcare
utilization, and prevalence of sexually transmitted infections (STIs). The evaluation was an
observational study with controls in a “before and after” design. Both the baseline survey and
the 16 month follow-up survey were designed to select a representative sample of men and

women between 15 to 49 years of age from the area within Mbarara, Kiruhura, Ibanda,
Isingiro and Bushenyi districts.
Table 1.1: Background characteristics in 2006 and 2007 surveys

Background characteristics (age group, marital status, religion, education,
residence-rural/urban, district, wealth quintile) among respondents aged 15-
49 by gender.
Characteristic 2006 (%) Sample 2007 (%) Sample
Age
15-24 25% 623 31% 816
25-34 40% 1019 40% 1047
35-49 36% 904 30% 775
TOTAL 100% 2546 100% 2638
Sex
Women 58% 1486 49% 1268
Men 42% 1056 51% 1309
TOTAL 100% 2542 100% 2577
Marital status
Never married 14% 369 24% 613
Currently married* 74% 1900 66% 1713
Divorced, separated 6% 158 7% 189
Widowed 5% 134 3% 86
TOTAL 100% 2561 100% 2601
Rural-urban status
Urban / Trading centers 42% 1097 45% 1192
Rural 58% 1498 55% 1460
TOTAL 100% 2595 100% 2652
Education
None 14% 369 10% 274
Some Primary 35% 918 34% 887
Completed Primary 9% 230 22% 572
Some Secondary 20% 521 23% 606
Completed secondary 22% 565 11% 293
TOTAL 100% 2603 100% 2632
Wealth quintile
Lowest 20% 526 20% 541
Second 24% 635 23% 598
Middle 19% 506 20% 541
Fourth 19% 498 20% 535
Highest 18% 475 17% 448
TOTAL 100% 2640 100% 2663
Religion
Protestant 56% 1425 56% 1465
Catholic 34% 870 33% 869
Muslim 9% 226 9% 240
Other 2% 43 2% 48
None <1% 4 <1% 4
TOTAL 100% 2568 100% 2626
In the 2006 baseline survey 2,568 respondents were interviewed and in the 2007 follow-up
2,626 respondents were interviewed. In 2006, 58 percent of respondents were women and
25 percent were young people between 15 and 24 years of age. In 2007, 49 percent of
respondents were women and 31 percent were between 15 and 24 years of age. In both
surveys, the largest group of respondents was aged between 25 and 34 years (40 percent).
Most respondents were currently married (77 percent in 2006, 63 percent in 2007); most

lived in rural areas (58 percent in 2006, 55 percent in 2007) and one-third of respondents
had received some primary education (35 percent in 2006, 34 percent in 2007).
The Uganda OBA program began distributing vouchers in July 2006. The program on behalf
of the Ministry of Health contracted 17 private clinics on a negotiated fee for service. Clinics
must meet accreditation standards before a contract can be signed and, once they are
members of the program, must comply with STI treatment guidelines in order to receive
payment for services provided. Vouchers and health information are marketed to patients
who feel they may have been exposed to, or actively suffering from, an STI. Clients
purchase the subsidized double voucher for themselves and a partner and then take their
half of the voucher to a clinic where it is exchanged for screening and treatment services.
The facility is reimbursed for the cost of the service after it has submitted a claim to the
Voucher Management Agency. Reimbursement rates range from 5000 shillings ($3.10) to
more than 50,000 shillings ($31) in a few cases. Providers can be reimbursed for two lab
tests (3,000 shillings each), a consultation fee (5,000 shillings), and prescribed drugs from a
national standard formulary.
At the start of the program 17 clinics were contracted across the four districts of Ibanda,
Isingiro, Kirihura and Mbarara. A map on the following page indicates where the clinics are
located, represented by green crosses. The main commercial town in the region is the
university town of Mbarara lying on the principal transport route between Kampala to the
east and Rwanda and Congo to the west. The regional population is 1.1 million with Ibanda
and Mbarara the more densely populated districts. Kirihura district (contains Kazo and
Rushere towns) to the northeast is a large and relatively wealthy rural region where the main
business is cattle-keeping. Isingiro (contains Kabingo town) to the south is sparsely
populated and poorly connected by roads, and there are two large refugee camps within the
district.
By early April 2008, more than 14,000 voucher-bearing patients had visited clinics and
21,000 patient visits were reimbursed. Since the program began, utilization has varied
tremendously between and within clinics. The map on the following page indicates
cumulative clinic utilization within subcounties. Each subcounty is shaded increasingly
darker as the number of OBA patients from that subcounty increases. The darkest
subcounties indicate where the highest number of patients originated and those subcounties
are not surprisingly where the clinics are located.
It should be noted too that the surrounding subcounties had large patient numbers in total.
The aggregate number of patients from non-OBA subcounties is two times greater than the
number of patients from OBA subcounties.

SECTIO II: K OWLEDGE OF OBA PROGRAM A D STIs I 2006 & 2007
2.1 How well did respondents know about the voucher?
Media preferences do not differ across the three intervention arms and gender. Radio is
consistently the dominant medium to learn about STIs. In 2006 over 65 percent of
respondents indicated “radio” as their preferred means to learn about STIs and in 2007 more
than 70 percent named “radio” their preferred source for STI information. In both surveys
“friends and peers” and “government clinic staff” were distant second and third options as
sources of STI information.
Given the reported preferences for radio, it appears to MSI made a good decision to use
radio to market the OBA voucher and educate populations on STI signs and symptoms. The
OBA program began promoting the STI voucher in late June 2006 using radio
advertisements, talk shows, and community mobilizations. The 2006 baseline household
survey was carried out July 10 to August 22. In those six weeks, 24 percent of male
respondents and 20 percent of female respondents already had heard of the STI voucher.
By 2007, over 50 percent of respondents had heard of the STI voucher.
Awareness of OBA STIs voucher

Heard of voucher, seen voucher, and know correct voucher price among
respondents.
2006 (%) Sample 2007 (%) Sample

General population
Heard of voucher 21% 547/2532 51% 1336/2604
Know cost of voucher <1% 4/2532 43% 1131/2604
Seen voucher <1% 26/2532 <1% 198/2604
Among those w/ 2+
symptoms
Heard of voucher 21% 321/1530 50% 722/1444
Know cost of voucher <1% 3/1530 43% 616/1444
Seen voucher 1% 18/1530 8% 109/1444
Among those w/ reactive

TPHA
Heard of voucher 19% 75/393 47% 149/316
Know cost of voucher 0% 0/393 14% 44/316
Seen voucher <1% 1/393 8% 24/316
By the 2007 follow-up survey, 43 percent of the general population correctly named the
voucher price of 3000 shillings. That level of penetration in the general population suggests
that the marketing efforts were extensive. Marketing messages appear to have been well
targeted to the general population. Of the 1131 respondents in 2007 who gave the correct
voucher price, 43 percent reported having 2 or more STI symptoms in the past 6 months.
However, in the group most at need – those who had a reactive TPHA result – the market
penetration was no higher than the general population. It would be better if messages and
marketing media reached a higher proportion of the type of respondent who had a reactive
TPHA result.
Beginning in June 2006, Marie Stopes International (MSI) conducted an extensive health
education and marketing campaign on radio and in community gatherings to sell vouchers

and educate listeners on the signs and symptoms of sexually transmitted infections (STIs).
Radio coverage was extensive in the region. In some months, all five regional stations
carried advertisements, game shows, call-in programs, and hosted talk sessions about the
Healthy Life voucher and sexually transmitted infections.
In the following graph (“Media and patient claims”), the yellow line shows patient visits per
month. The axis on the left shows hours of marketing activity for both community
presentations, shown in blue, and radio which is shown in dark red. The number of
marketing hours spent in the community increased considerably beginning in February 2007
with the most community hours recorded in May, June and September. Radio efforts
expanded in July 2007 and involved 5 regional radio stations. Consequently, the number of
radio hours of exposure increased three-to four-fold in the months of July, August and
September and includes talk shows and advertisements. The absence of radio broadcasting
in October reflects budget constraints. The number of client visits more than doubles in the
same three month period and suggests that radio exposure, which has the potential to reach
a very large number of people in the region, particularly if several different stations are used,
has resulted in a considerable increase in the numbers of clients using the program.
Media and patient claims
40 3000
35
hours of marketing activity
2500
30
2000
25
Radio
patients
20 1500 Community
Claims
15
1000
10
500
5
0 0
De -06
Ju 6
Fe 07
Ju 7
Au 6
M 07
Ap 07
Au 7
Se -06
O 06
Ja 0 6
M 7
Se 07
O 07
Ju 07
No 06
7
l-0
l-0
0
r-0
-0
n-
n-
n-
b-
-
p-
c-
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-
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ar
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ay
ct
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month
2.2 How well did respondents know about symptoms?

Respondents were asked to name symptoms and sequelae associated with sexually
transmitted infections. Eight of nine STI symptoms were more commonly recognized in the
follow-up survey than in the baseline. “Genital itch” was the only symptom more commonly
recognized in 2006 (62%) than in 2007 (53%). Sixty-nine percent of respondents in 2006
and 79 percent of respondents in 2007 were able to recognize two or more STI symptoms.

Comparison of Respondent Awareness of STIs by Year
Awareness of symptoms of sexually transmitted infections (STIs) among respondents aged
15-49 at baseline (2006) and 16 month follow-up (2007). Respondents were asked to name,
without prompting, STI symptoms.
2006 (%) Sample 2007 (%) Sample T-test p-value

Known STI symptoms:
36.7 (34.7, 48.9 (46.9,
Abnormal discharge 38.8) 780/2123 50.8) 1272/2602 p<0.00
16.7 (14.9, 46.1 (44.2,
Foul smell with discharge 18.8) 247/1466 48.1) 1200/2601 p<0.00
29.2 (27.4, 45.5 (43.6,
Burning urination 31.0) 724/2480 47.4) 1185/2603 p<0.00
11.9 (10.6,
Inflammation; redness 4.6 (3.8, 5.4) 113/2460 13.1) 308/2596 p<0.00
20.0 (18.4,
Swelling genitalia 9.3 (8.1, 10.4) 230/2481 21.5) 520/2599 p<0.00
37.9 (36.0, 37.7
Genital ulcer 39.8) 954/2514 (35.8,39.5) 978/2597 p=0.83
62.0 (60.1, 53.1 (51.1,
Genital itch 63.9) 1577/2543 55.0) 1382/2604 p<0.00
13.7 (12.3,
Weight loss 6.0 (5.1, 6.9) 148/2469 15.0) 355/2598 p<0.00
Hard to conceive 1.3 (0.8, 1.7) 31/2471 6.8 (5.8, 7.7) 176/2591 p<0.00
Figure: Number of signs and symptoms of STIs recognized by respondents
To test whether the observed improvements in knowledge may be due to common

confounders, nine multivariable logistic models tested the association between awareness of
each of the STI symptoms and the survey year controlling for respondent age, sex, and
presence of an OBA provider in the respondent’s parish. In eight of the nine models, the
survey year was significantly associated with an increased awareness of STI symptoms.
A multivariable logistic model was fit to test whether the survey year and presence of an
OBA clinic in respondents’ parish is associated with an increase in knowledge of STI
symptoms controlling for household wealth, respondent sex, respondent age, and education.
A summary measure of STI signs and symptoms was created with scores from 0 to 9. 32%
of respondents knew more than 2 or more signs and symptoms in 2006 and 16 months later

53% of respondents knew 2 or more signs and symptoms. The improved level of recognition
is significantly associated with the year of survey.
A Poisson model tested associations between knowledge of STI symptoms and the year of
survey, controlling for household goods, respondents’ age, respondents’ sex, respondents’
level of education, whether respondent lived in a parish with a contracted clinic, and an
interaction term for living near a contracted clinic and survey the year.
λ = a + OBA year(x1) + OBA clinic (x2) + Age(x3)+ Household goods (x4) + Education (x5) +
Sex (x6) + OBA year * OBA clinic (x7)
Term Coefficient rates 95% confidence

(error) interval
Survey year 1.50 (0.04) 1.41, 1.59 p<0.001
Contracted OBA clinic present 1.06 (0.04) 0.98, 1.15 p=0.08
Household goods 1.04 (0.01) 1.02, 1.05 p<0.001
Age 1.04 (0.04) 0.97, 1.11 p=0.46
Education 1.04 (0.01) 0.02, 0.06 p<0.001
Sex 1.01 (0.02) 0.96, 1.05 p=0.73
Interaction term (OBA x 0.89 (0.04) 0.81, 0.97 p=0.01
survey year)
Respondents were 50% more likely to know 2 or more STI signs and symptoms in the
second year compared to the first. MSI’s social marketing campaign involved wide spread
radio advertisements, talk shows, and call-in programs with health education and voucher
marketing messages. We expected knowledge of STI symptoms to improve across the
region irrespective of whether respondents lived near an OBA clinic. The results indicate
that the 16 months between program launch and the follow-up survey were the most
important factor associated with knowledge of STIs.
Interestingly, STI knowledge is negatively associated with interaction term that compares the
difference between OBA and non-OBA parishes at baseline to the difference between OBA
and non-OBA parishes at follow-up. The interaction term is negatively associated with STI
knowledge because the difference in STI knowledge between OBA and non-OBA parishes
was lower in 2007 than in 2006 and that relationship remains true after controlling for sex,
age, wealth, education and other independent variables. At first glance it’s a counter-intuitive
finding. While I cannot offer reasons a priori for the finding, I am not surprised that the
interaction term is not significant. The ‘knowledge enhancing’ component of OBA played
largely on radio stations accessible to wide sections of western Uganda, reaching far beyond
the areas nearby contracted facilities.
In my opinion it was important sign of program impact that a significantly higher percentage
of respondents were able to name seven of nine STI signs in 2007 compared to 2006. It
suggests that health education efforts were working well across the entire region.

SECTIO III: STI UTILITIZATIO I 2006 A D 2007
The first step to understanding healthcare utilization is to determine the disease burden.
The OBA program seeks to improve the screening uptake and quality of STI treatment,
especially among patients who would otherwise have gone undiagnosed. There are two
questions we want to address:
1. Who reports having STI symptoms?

2. Of those reporting STI symptoms, who seeks treatment?
We test whether demographic variables (respondent sex and age), socio-economic factors
(household wealth and respondent education), and behavioral variables (sexual behaviors)
are associated with self-reported STI symptoms and accessing STI treatment.
We want to know who, among those reporting an STI symptom, has sought STI treatment. It
is assumed that the OBA program would be associated with an increase in use of STI
treatment in the second survey.
3.1 Who reports having STI symptoms?
In this analysis, we seek to identify characteristics of the populations burdened by STIs. The
first table shows the distribution of STI symptoms in both surveys. There is no significant
difference in the proportion of self-reported STI symptoms between survey years – the
burden of respondent-recognized STIs remains the same in both years. Other measures of
self-reported STIs substantiate this finding.
In past 6 months have you or 2006 2007

your partner had symptoms
you thought might indicate an
STI
No 58% 60%
Yes 42% 40%
Pearson χ2 2.8,
p=0.09
The frequency of those reporting STI symptoms is tabled below by demographic, socio-
economic and risk behaviors categories to determine if any groups have disproportionately
greater disease burden in either year.
Proportion of respondents 2006 2007

who reported they or their
partner had 1 or more STI
symptoms
By Wealth Index
Low wealth (1) 33% 32%
Lower middle wealth (2) 28% 27%
Upper middle wealth (3) 23% 22%
High wealth (4) 16% 20%
2
Pearson χ 4.5,
p=0.21
In both years, the poorest quartile reported nearly twice the burden of STI symptoms as the
wealthiest quartile. There was no significant change in the frequency of STI symptoms by
wealth index in the two survey years.

Proportion of respondents 2006 2007
partner had 1 or more STI
symptoms
By Education Level
No education 13% 10%
Some primary 38% 38%
Completed primary 9% 24%
Some secondary 18% 21%
Completed secondary 21% 8% Pearson χ2 135.2,
p<0.001
By Risk Factor
Having more than 1 sex partner 29% 31% Pearson χ2 1.0, p=0.31
Women 62% 51%

2
Men 38% 49% Pearson χ 22.1, p<0.01
In both survey years, about 40 percent of respondents reported having one or STI symptoms
in the previous six months. Of those respondents, about one-third had more than one sex
partner in the same period; two-thirds did not have more than one partner. In both years,
more women than men reported STI symptoms, although the second year was nearly
balanced (51 percent women to 49 percent men).
This next table presents the respondents’ demographic, socio-economic and risk behavior
characteristics combined from both years to determine whether STI symptoms affect
respondents equally. For instance, are STI symptoms reported with the same frequency by
respondents with few household goods compared to respondents with many household
goods?
Proportion of respondents 2006 & 2007 Combined

partner had 1 or more STI No 1 or more
symptoms symptoms symptoms
By Wealth Index
Low wealth (1) 57% 43%
Lower middle wealth (2) 57% 43%
Upper middle wealth (3) 60% 40%
High wealth (4) 63% 37% Pearson χ2 10.9,
p=0.01
By Education Level
No education 61% 39%
Some primary 55% 45%
Completed primary 56% 44%
Some secondary 63% 37%
Completed secondary 63% 37% Pearson χ2 29.6,
p<0.01
By Risk Factor
No more than 1 sex partner 62% 38%
More than 1 sex partner 52% 48% Pearson χ2 41.2
p<0.01
Women 57% 43%

Men 62% 38% Pearson χ2 10.2,
p<0.01

The results indicate that self-reported STI symptoms are higher for those with poorer socio-
economic status (both wealth and education), self-reported STI symptoms are greater
among men, and not surprisingly STI symptoms are reported among respondents who also
report having at least one sex partner outside their principal relationship.
3.2 Of those reporting STI symptoms, who seeks treatment?
The next question to ask is who among respondents with STI symptoms utilized STI
treatment services. For the OBA program, it is useful to know if a healthcare subsidy would
be the appropriate response to the utilization patterns in the region.
Recall of healthcare utilization deteriorates over time although different health events are
remembered with varying precision. Seeking treatment for STI symptoms is not a life-
changing event like delivering a baby and as a result we chose a six month recall to balance
recall error and the need for a good number of positive responses.
Of respondents with STI symptoms, 2006 2007

how many seek treatment?
Women
No treatment seeking 66% 62%
Treatment seeking 34% 38% Pearson χ2=1.8, p=0.20
Men
No treatment seeking 63% 63%
Treatment seeking 37% 37% Pearson χ2= 0.05,
p=0.83
Provider type for STI treatment

Private drug shops, clinics, and 60% 54%
hospitals
Govt clinics, hospitals and mission 40% 46% Pearson χ2= 2.96,
hosp. p=0.08
The relative proportion of utilization of STI treatment did not significantly vary between
baseline and follow-up for men or women. In both years, more than 50 percent of
respondents used private facilities for STI treatment, although the proportion is non-
significantly lower in the follow-up survey.
Satisfaction with STI Public Private

treatment by provider
type
2006
Satisfied 35% 41%
Somewhat satisfied 37% 39%
Dissatisfied 29% 20%
2007
Satisfied 29% 38%
Somewhat satisfied 46% 38%
Dissatisfied 25% 24%

Interesting to note that in both years the respondents who visited private facilities were the
most satisfied with their care. It is not certain that the level of care was objectively better at
private clinics, but the patients’ perception of overall satisfaction is consistent in both years.
Barriers to STI treatment
Respondents were asked whether they had recently had STI symptoms and if yes, whether
they had sought treatment. Of those who had symptoms but did not seek treatment, they
were asked to explain why.
Reasons for not seeking STI 2006 2007

treatment among female
respondents in 2006 and 2007
Women’s reasons for no treatment

Lack of money 82% 79%
Lack of time 6% 10%
Treatment makes no difference 6% 5%
Distance to provider 3% 3%
Lack of trust in providers 3% 3%
Pearson χ2= 218, p<0.01
In both survey years, “lack of money” was the most common reason for not seeking STI
treatment among respondents reporting STI symptoms and no service utilization.
Frequencies of response were consistent between the two years. Six percent of respondents
in the first year and 10 percent in the second survey noted a “lack of time” kept them from
seeking STI treatment. Distance to provider was surprisingly an infrequent response. It is
possible that the “lack of money” response included the cost of transport in the mind of some
respondents.
Choice of provider among those who

sought STI treatment
OBA Non-OBA OBA Non-OBA
parishes parishes parishes Parishes
2006 2006 2007 2007
Private for-profit clinic (=4) 29 46 11 36
Government clinic (=6) 8 25 12 33
Government hospital (=9) 15 38 8 25
Self-medication (=1) 2 6 4 6
Private hospital (=8) 1 3 5 4
Traditional healer (=2) 0 2 0 4
Chemical seller/ Drug shop (=3) 2 8 3 6
Private not-for-profit clinic (=5) 4 6 2 4
Mission hospital (=7) 2 2 3 6
Total 63
A Poisson model of the frequency of unique STI treatment visits was fit with the following
predictors: household purchased goods score, household agricultural assets score,
respondent age, respondent sex, respondent education, the survey year, whether the
respondent lived in a parish with a contracted clinic, and how many STI signs and symptoms
the respondent knows.

Term Coefficient 95% CI
Household goods 0.013 (-0.028, 0.055) p=0.53
Agricultural assets 0.007 (0.004, 0.009) p<0.001
Age 0.011 (0.005, 0.018) p<0.001
Sex -0.199 (-0.314, -0.083) p=0.001
Education 0.004 (0.056, 0.037) p=0.68
Survey year 0.318 (0.204, 0.431) p<0.001
Contracted clinic in parish 0.188 (0.149, 0.228) p<0.001
Knows STI symptoms & signs 0.136 (0.011, 0.260) p=0.03
The model results indicate that the number of visits for STI treatment in the past six months
has a positive association with male respondents, older age, greater knowledge of STI
symptoms, as well as more household agricultural assets, living in a parish with a contracted
clinic, and being surveyed 16 months after the program’s start.
3.3 How many patients traveled from subcounties without clinics?
At the beginning of the OBA pilot it was not known how far patients would be willing to travel
for STI treatment. Reviewing the claims forms, it is possible to roughly estimate willingness
to travel simply by looking at patients’ resident administrative area and the location of
contracted OBA clinics.
Reviewing nearly 15,000 claims records from July 2006 to April 2008 indicate 64% of
patients live in subcounties without a contracted clinic. The fact that the majority of patients
sought services outside their resident subcounty indicates that they are mobile and suggests
that the relatively small contracted facilities in the OBA program have catchment areas that
reach across neighboring administrative areas.
It is possible that the STI condition uniquely compels patients to seek care in areas far from
home where they will not be recognized. The same mobility may not be observed with other
healthcare services.
3.4 Poverty rate among voucher patients
The 2002 Uganda census estimated an absolute poverty line based on households’ ability to
purchase a basket of durable goods and consumables determined by the government to
represent required inputs for household well-being.
The poverty line is used to calculate “poverty rates” in administrative areas by dividing the
number of households living in poverty by the total number of households. A cautious
reader should note that the poverty rate does not indicate how poor the poor are in any given
area. It does not distinguish between a household whose consumption levels are very close
to the poverty line, and a household whose consumption levels are far below it. Poverty
rates also do not distinguish between lightly and densely populated areas; for instance, an
area with 10 households of which 9 are below the poverty line will appear to be much poorer
than an area with 500 households of which 250 are below the poverty line.
The percent of households living in poverty ranged from less than 10 percent to more than
40 percent in the subcounties where voucher patients reside. The subcounty poverty rate
had a significant inverse correlation (r= -0.44, p< 0.001) with whether the subcounty had a
contracted clinic. Clinics were more likely to be located in subcounties with a lower poverty
rate.

The table below indicates the distribution of voucher patients from subcounties with and
without contracted clinics by poverty rate in patients’ resident subcounty. More patients from
low poverty areas used contracted clinics in their own subcounty. Patients from high poverty
areas had to travel outside their resident subcounty to receive care from a contracted clinic.
More than 40% of voucher-bearing patients treated between July 2006 and April 2008 came
from subcounties with poverty rates above 35 percent.
Total Subcounties with Subcounties w/o

clinics clinics
Percent of HH Percent Patients Percent Patients Percent Patients
below poverty in
patients’ resident
subcounty
>5% 4% 549 10% 549 0 0
5%-14% 11% 1677 31% 1677 0 0
15%-24% 41% 6075 34% 1837 45% 4238
25%-34% 36% 5433 25% 1366 43% 4067
35%-44% 8% 1182 0 0 13% 1182
3.5 How competitive was voucher utilization?
Herfindahl-Hirschman index (HHI) is a measure of market concentration. Here, it measures

the extent to which patient visits are concentrated at a few clinics. If there voucher-bearing
patients visited clinics in equal numbers each month, the HHI would score the market share
among the 18 clinics as 555, which is calculated as 1/18 of the market and multiplied by
10,000 to arrive at nice round integer. If only 14 clinics are operating, the 1/14 of the market
multiplied by 10,000 would be 714. If a single clinic were to dominate all clinics, the HHI
would equal 10,000.
3000 3000
2500 2500
HHI market concentration
monthly voucher sales

2000 2000
1500 1500
1000 1000
500 500
0 0
6
7
07
07
08
6
7
06
06
07
07
07
07
07
08
06
7
-07
0
0
J ul-0
J ul-0
De c-0
Oc t- 0
De c-0
No v-
No v-
J an-
J un-
J an-
F eb-
M a r-
A pr-
F eb-
A ug-
S ep-
A ug-
S ep-
Oc t-
M ay
Herfindahl-hirschman index Voucher sales
The take away message is that a lower score means a more diversified market. We can
follow the concentration of patients at clinics month-to-month. Note that aggregate monthly
utilization does not correlate well with concentration. In the months that the HHI scores
approached 1000, voucher utilization was alternately low and high, which suggests that clinic

activity month to month is fluid. That makes sense given the nature of the diseases treated;
different STIs occur in different clusters of sexual networks. As the voucher program
matured in 2007 and expanded the number of vouchers to a record of more than 2500 in
August, the measure of market concentration – HHI – fell to its lowest value in 2007.
Voucher sales fluctuated month-to-month due to both demand and supply issues. On the
supply side, the OBA management agency was faced with short term funding constraints
and management problems that led to voucher rationing from September to December 2007.
The fall in voucher sales after August 2007 reflects to some degree funding constraints that
limited reimbursement levels. As the program cut back on vouchers, the voucher market
became less competitive as evident in the previous graph.

SECTIO IV: PREVALE CE OF SYPHILIS I 2006 A D 2007
Important factors in the incidence of any infectious disease are the pathogen’s virulence and
duration. Breaking the transmission cycle of sexually transmitted infections requires either
changing sexual behavior or increasing the numbers of treated STI cases within sexual
networks (partner referral or contact tracing). Large interventions in contexts similar to the
OBA program in contemporary rural Uganda have shown it is possible to break STI
transmission through health education, community-based drug distribution, and improved
healthcare delivery.
The output-based aid (OBA) program subsidizes access to STI treatment and educates
radio listeners on STI risks. Because of the health education and voucher sales combination,
the OBA program may affect prevalence of curable STIs through both prevention and
treatment: by curing infected persons and preventing infection through the promotion of
behavior change. Both pathways are plausible in the Uganda OBA project.
OBA intervention is the combination of radio health education

and marketing messages to sell vouchers for treatment at
contracted clinics.
Patients visit OBA Vouchers shared

facility. Some with partner.
patients are cured. Some partners use
it. Some are cured.
Population
prevalenc
e affected
Prevalence of syphilis 2006 2007 Significance test

among all respondents
TPHA 18% 12% T= 5.15 p<0.01
VDRL 6% 4% T= 2.97 p<0.01
Combined TPHA & VDRL 3% 3% T= 0.34 p=0.69
Syphilis was the most common STI and operationally the most robust measure. In each
village surveyed, the field team was able to set up a lab with rapid diagnostic TPHA strips to
test finger pricks for T. pallidum antibodies. Blood draws were also taken for VDRL lab
analysis at Mbarara University. Using TPHA alone, 18% of respondents had reactive results
in 2006 and 12% in 2007. In the VDRL lab results, 6% of respondents had reactive results
in 2006 and 4% in 2007. When TPHA and VDRL results are combined, only 3% of
respondents were reactive in both 2006 and 2007. There are likely many false positives in
the TPHA and VDRL results. The combined use of both tests for screening and confirmation
is standard practice.

Proportion of respondents 2006 2007 Significance
with reactive VDRL tests
By wealth index
Low wealth (1) 8.3% 4.5% T= 2.5 p=0.01
Lower middle wealth (2) 5.4% 3.8% T= -0.1 p=0.92
Upper middle wealth (3) 6.6% 5.6% T= -1.8 p=0.07
High wealth (4) 4.6% 3.6% t=-1.2 p=0.23
By education level
No education 8.4% 5.7% T= 1.1, p=0.25
Some primary 7.5% 4.8% T= 0.8, p=0.40
Completed primary 8.9% 5.3% T= -2.9 p<0.01
Some secondary 4.4% 2.6% T=0.1 p=0.94
Completed secondary 4.4% 4.5% T=0.9 p=0.33
By risk factor
No more than 1 sex partner 6.1% 3.9% T=0.2, p=0.8
More than 1 sex partner 6.4% 6.1% T=2.9, p<0.01
Sought STI treatment recently

No treatment sought 6.7% 5.0% T=1.3, p=0.20
Treatment sought 7.7% 4.1% T=2.1, p=0.04
Using VDRL results for adequate sample size, the distribution of respondent characteristics
are presented in the table above. There were fewer reactive test results at each level of
each characteristic in 2007 compared to 2006. Although the poorest quartile had nearly
double the level of syphilis at baseline in 2006, by 2007 the level of syphilis among the
poorest respondents was only 1 percent higher than the richest. A similar trend is observed
between the least educated and the most educated in 2006 and 2007.
Test results reflect the common risk factors for STIs. Respondents with reactive VDRL
tended to have lower education levels, lower wealth quartiles, have more sex partners and to
not have sought STI treatment recently.
The lower prevalence in 2007 occurred across both treatment and control areas. The cross-
over mentioned in the introduction and explained in greater detail in the appendices is likely
one reason for the significantly lower prevalence in 2007.

CO CLUSIO
In this evaluation we described cross sectional patterns in the general population’s

knowledge of STI symptoms, STI utilization, and the STI burden in the region around the
OBA facilities of western Uganda.
Evaluation looks for impacts in both the facility populations and general populations.
Utilization at OBA facilities is the first level to anticipate changes in utilization patterns. The
2007 clinic evaluation (Lowe, Bellows) found a tremendous demand at contracted clinics
over the year before OBA. However, the general population surveys found no significant
increase in utilization in the region. Population effects are only going to be observed if the
“treatment effect” – in OBA, the presence of vouchers and contracted clinics – is sufficient to
be a large fraction of all utilization in the region. With 16 OBA clinics in a region with 143
facilities that treat STIs, it is not surprising that voucher use was not high in the surveys.
Recommendation 1: Increase the number of contracted facilities to boost population

impact
Radio appears to be an effective medium to reach distant populations with health education
and voucher marketing messages. Providers report that utilization increases at their
facilities in the week after a large radio campaign. Radio marketing has not been consistent
in the project but could be improved and made more consistent.
For the type of respondents who are most in need of the voucher – those who had a reactive
TPHA result in the surveys – the market penetration was no higher than the general
population. It would be better if messages and marketing media reached a higher proportion
of the type of respondent who had a reactive TPHA result.
Recommendation 2: Increase the use of radio to encourage partners of any STI

patients to seek treatment.
Voucher distribution has surged and fallen at different points in the first two years as the
OBA program has dealt with the effects of short-term funding. Changes in voucher
availability, particularly in the second half of 2007, has affected provider morale and can
cause providers to leave the program. Greater stability in voucher distribution is needed.
Recommendation 3: Make the supply of vouchers consistent.
Claims data were reviewed for utilization trends. Unfortunately, the claims data did not use
standard place names for villages. It is not possible to map many of the patients back to
their village and the result is an imprecise measure of where patients originate.
Recommendation 4: Use standardized place names in the claims management

software
The OBA program in the first two years in Uganda appears to have improved knowledge of
STI signs and symptoms and increased utilization at contracted clinics compared to the
same clinics’ utilization the year before OBA. The OBA program also is associated with a
dramatic decline in syphilis cases 16 months after the program was launched. The decline
occurred in areas nearby and far from the contracted clinics. It remains to be seen whether
the program can be credited with the observed lower prevalence.

APPE DIX 1: Female Contraceptive Use and Births
Information about use of contraceptive methods was collected from female respondents
aged 15-49 by asking them if they were currently doing something or using any method to
delay or avoid getting pregnant. Table 6 shows the level and key differentials in the current
use of contraception by method as reported by female respondents. Contraceptive methods
are grouped into two types in the table, namely modern and traditional methods. Modern
methods include sterilization, pill, IUD, injectables, implants, male condom, and lactational
amenorrhoea (LAM). Traditional methods include periodic abstinence (rhythm method) and
withdrawal.

Contraceptive use by background characteristics among all female respondents 15-49 years old
Characteristic Modern method Traditional method
Any Periodic
Any modern Sterili- IUD/ Inject- Tradition. abstinenc With-
method method zation Pill Coil ions Implant Condom method LAM e drawal Not using Percent Number
All women 32.4% 0.8 4.6 0.2 15.5 0.5 4.3 1.9 2.0 2.4 66.9
Age
15-24 34% 0 4.9 0 11.3 0.2 5.8 3.0 2.8 0.7 70.9 100.0
25-34 43% 0.2 4.8 0.4 20.8 1.2 3.0 1.6 2.0 3.6 62.5 100.0
35-49 32% 2.8 3.9 0 13.9 0 4.2 0.8 1.1 2.8 70.6 100.0
Residence
Urban / Trading
centers 32% 1.0 5.8 0.3 17.8 0.9 5.4 2.4 2.2 2.6 61.6 100.0
Rural 44% 0.7 3.7 0 14.0 0.3 3.4 1.4 1.8 2.3 72.3 100.0
Education
None 23% 0.6 3.1 0 12.5 0.6 1.3 0 1.9 0.6 79.4 100.0
Some Primary 33% 0.9 4.7 0 13.0 0.2 3.2 2.1 2.4 3.0 70.3 100.0
Completed Primary 44% 0.8 5.3 0.8 17.8 0.8 6.1 1.9 2.3 1.5 62.3 100.0
Some Secondary 38% 0.7 5.5 0 16.8 0.7 3.8 2.4 1.0 1.7 67.4 100.0
Completed secondary 55% 1.8 1.8 0 22.9 1.0 10.1 2.8 2.8 4.6 52.3 100.0
Religion
Protestant 36% 0.8 5.3 0.3 15.6 0.6 3.2 1.5 1.8 2.1 68.5 100.0
Catholic 38% 1.2 3.5 0 15.5 0.5 5.7 1.9 2.5 1.9 67.4 100.0
Muslim 38% 0 5.2 0 18.3 0 5.2 4.4 0.9 3.5 62.6 100.0
Other 26% - - - 11.5 - - 3.9 3.9 3.9 69.3 100.0
.

Number of children ever born to female respondents 15-49 years old
Number of children
Numbe Mean number Mean number
r of of children of living
Age 0 1 2 3 4 5 6 7 8 9 10+ Total women ever born children
15-24 1.2 49.6 25.0 13.9 7.0 1.6 0.8 0.4 0.4 - - 100.0 244 1.9 1.6
25-34 1.5 12.7 17.5 21.8 18.3 13.8 7.1 5.4 0.9 0.9 0.2 100.0 464 3.5 3.0
35-49 0.9 4.4 7.0 9.6 14.9 15.2 11.1 11.1 10.2 6.4 9.0 100.0 343 5.7 4.5
Total 1.2 18.5 15.9 16.1 14.6 11.4 6.9 6.1 3.8 2.5 3 100.0 1051 3.8 3.2
Currently married or co-habitating women
15-24 0.5 46.4 26.0 15.8 7.7 2.0 1.0 0.5 - - - 100.0 196 1.9 1.7
25-34 1.0 11.7 16.2 21.9 19.0 14.3 7.8 5.7 1.0 1.0 0.3 100.0 384 3.6 3.1
35-49 0.8 3.4 7.2 7.9 13.6 15.9 12.1 10.6 10.9 7.6 10.2 100.0 265 5.9 4.6
Total 0.8 17.1 15.6 16.3 14.6 11.9 7.6 6.0 3.9 2.8 3.3 100.0 847 4.0 3.2
The table above shows that the mean number of children ever born to all female respondents is 3.8 children. The mean number of living
children is 3.2. Among currently married women, the mean number of children ever born is 4.0, and the mean number of living children is 3.2.
As expected, the mean number of children ever born and living increases with age. This table shows fertility in Uganda continues at high levels.
For example, 54 percent of women aged 15-24 have given birth to at least two children while 11 percent have given birth to four or more
children.

Delivery location and skilled attendants
Site of most recent delivery
Percent distribution of respondents by urban and rural groups regarding their location of
most recent delivery.
Age
(15-49 year old respondents)
Urban & trading Rural Total
centers
Site of last delivery Percent Number Percent Number Percen Number
t
Home
Respondent’s home 28.8 134 55.3 331 43.7 466
TBA’s home 1.7 8 4.5 27 3.3 35
Other home - - 0.5 3 0.3 3
Public Sector
Government hospital 32.5 151 16.0 96 23.4 250
Government health center 12.3 57 8.5 51 10.1 108
Government health/aid
post 1.1 5 0.7 4 0.8 9
Private Sector
Private clinic 3.2 15 1.5 9 2.3 24
Private for profit hospital 12.9 60 11.9 71 12.3 131
Mission hospital 7.3 34 0.8 5 3.7 39
TOTAL 100.0 100.0 100.0
Assistance at most recent delivery
Crude (unweighted) percent distribution of respondents by urban and rural groups

regarding the level of assistance during the most recent delivery.
Age
(15-49 year old respondents)
Urban & trading Rural Total
centers
Assistance at last delivery Percent Number Percent Number Percen Number
t
Health Professional
Doctor 8.2 38 5.5 33 6.7 72
Nurse/Midwife 58.8 273 33.5 201 44.6 476
Med. assistant/clinic.
officer 1.1 5 1.0 6 1.0 11
Nursing aide 3.2 15 2.7 16 2.9 31
Other person
Traditional birth attendant 9.1 42 15.7 58.3 12.7 136
Relative/friend 16.6 77 32.8 197 25.7 274
No one 1.9 9 6.0 36 4.2 45
Other / Missing 1.1 5 2.8 17 2.2 23
TOTAL 100.0 100.0 100.0
27
28
APPE DIX 2: Spatial implications in clinic utilization
Two maps are presented here. The map on the left shows cumulative numbers of
patients by subcounty up to April 2007. The map on the right presents cumulative
patient numbers from their subcounty of origin up to July 2007. Note the subcounties of
the southern Isingiro district, highlighted in the area circled in the lower portion of the
map. Several large community-based health education mobilizations were conducted
over the initial 10 months of the OBA program, despite the fact that the nearest clinic
was only accessible by dirt road to Mbarara 30 kilometers away. During that period
there were very few OBA patients who came from this region. In the same period, there
are several subcounties to the north with quite high numbers of cumulative patients and
not surprisingly these are located near clinics or near roads that connect to contracted
clinics.
At the end of April 2007, a new clinic was opened in Kabingo, the main town in Isingiro
district. Three months after opening, OBA clinic visits by Isingiro district residents had
increased dramatically and the map on the right clearly shows this. Many more people
from the subcounty in which the clinic is located sought treatment and people also began
visiting the clinic from nearby subcounties to the south.
It appears that despite extensive BCC marketing, there may have been a maximum
distance that people would travel to seek treatment given the trade-offs in time and cost.
It is also interesting to see from this slide that in areas of high population density, such
as the towns of Ibanda, Kazo and Rubindi to the north, there was consistently high use
of the clinics over the course of the program. It was anticipated that these would be
areas of high demand for STI treatment, and clinic use seems to bear this out.
29
APPE DIX 3: Data collection methodology
Objective
The objective of the paired population surveys is to detect a change in respondent
attitudes, respondent utilization, and prevalence of STIs. The evaluation was an
observational study with controls in a “before and after” design. Both the baseline and
follow-up surveys were designed to select a representative sample of men and women
between 15 to 49 years of age from Mbarara, Kiruhura, Ibanda, Isingiro and Bushenyi
districts.
Target Population
The target population was persons between 15-49 years of age in the old Mbarara
district (redrawn in 2006 as Kiruhura, Ibanda, Isingiro and Mbarara districts) and
Bushenyi district parishes containing private clinics. In both surveys, a sample of
respondents was selected from a four-stage design using population weights from the
2002 Uganda census.
Sample Size
Under the assumption of simple random sampling, a sample of 2,960 individuals would
enable us to detect a difference of three percentage points in population estimates of
disease burdens between baseline and follow-up surveys with 80% power using a one-
sided statistical test at 5% level of significance. For sampling purposes, we assume that
the prevalence of baseline serologic syphilis is 9.6% based on previous regional
population surveys.
Because the sample is not a simple random sample but a stratified sample selected
using a multi-stage cluster design, the detectable difference is likely to be larger or the
power of detecting a difference of three percentage points will be smaller than 80%.
This is due to the increased variance of the estimate based on unequal probabilities of
respondent selection in a cluster design must be corrected to be comparable to the ideal
equal probability of selection in a simple random sample of persons. This increase in
variance is known as design effect.
In the four stage design, the first sample of parishes were selected by a probability
proportional to population size, followed by a second sample of the villages from
selected parishes, again by a probability proportional to population size. The third
sample consisted of households enumerated from selected villages. Some economic
information at household level is measured in the survey. The remainder of the survey
was completed from the final sample, comprised of one household resident interviewed
at each selected household.
In such a design, you should consider the design effect, which is related to the intra-
class correlation coefficient. Intra-class correlation exists when the sampled unit
characteristics are dependent to a certain extent on cluster characteristics. This would
be the case if, for example, some parishes contain more OBA clinics, and others contain
limited functioning health services, as the dependent variable of interest at the level of
the household member. The design effect is defined to be the ratio of the variance from
the four-stage design over the variance of a simple random sample. In the case of
already existing data the design effect can be estimated using a bootstrap resampling
procedure or an intra-class correlation and variance correction estimation procedure.
30
When estimating the number of cases for sample size calculation, parameters such as
the prevalence, the expected response rate and the design effect have to be estimated
on the basis of previous experience. The design parameter should be larger than one if
the number of cases in each cluster equals one, i.e. the design parameter is one if there
is no cluster effect, and the design effect parameter should be no larger than the total
number of cases divided by the number of clusters (2960 cases in 82 villages). The
number of cases in each cluster should be equal (in this study n= 36). If it turns out to
not be possible in a few of the smallest villages (two villages have less than 45
households) a number will be selected close to the minimum observed number in the
clusters, meaning that in those villages, every household has a selection probability of 1
and the household member selected has a selection probability set as the inverse of the
household size. Usually one would expect the design parameter to be relatively close to
one in between the limits 1 and N/c. In this study, the design effect can be re-estimated
from bootstrapping methods after the survey to arrive at precise sampling weights. Stata
software package (version 10, Stata Corp.) survey design package adjusts for non-
simple sampling designs.
First Stage Selection

The Ugandan Office of Statistics (UBOS) has census data freely available down to
parish level. There are 240 parishes in the old Mbarara district ranging in size from 438
to 22,032 inhabitants (old Mbarara district registered 1,088,356 persons in 2002). In
Bushenyi there are 170 parishes in Bushenyi district ranging in size from 622 to 8,608
inhabitants (Bushenyi district registered 731,392 persons in 2002). In 2006, the Mbarara
district was split into four new administrative districts. However, for purposes of the
sampling frame, the previous administrative boundaries and 2002 census data are used.
Parishes (and the analogous “municipal ward”) constitute the first-stage sampling units
for sample selection. For the first selection stratum, parishes were stratified by whether
they have one or more private clinics. In Mbarara, private clinics participating in the
OBA scheme determined parish inclusion and in Bushenyi, clinics that would qualify for
OBA if it had been implemented there were included. By including the 15 Mbarara
parishes with OBA clinics in the first stage, respondents are essentially oversampled
from parishes with an OBA clinic. Eleven parishes from Bushenyi containing one or
more private clinics were also included. Fifteen non-OBA Mbarara parishes were
sampled from the remainder of Mbarara parishes (225) using probability proportional to
size (PPS) systematic sampling without replacement where size was defined by the total
parish population.
31
Table 1: Preliminary list of OBA clinics later reduced to 16 clinics in greater Mbarara
district
# of Parish
COUNTY OBA PARISH HH residents CLINIC NAME
1 Ibanda Bufunda 3,169 13,937 Ibanda Central clinic
2 Kashari Kabare 1,240 4,713 Angela Domiciliary Clinic
3 Ibanda Kagongo 1,800 8,791 Ninsima Medicare Clinic
4 Mbarara Municipality Kakoba 5,534 22,032 Busingye Clinic
5 Kashari Kakyerere 1119 5,186 Hope Clinic
6 Mbarara Municipality Kamukuzi 4083 15,676 Marie Stopes Uganda
7 Mbarara Municipality Kamukuzi 4083 15,676 Surgical Centre
8 Mbarara Municipality Kamukuzi 4083 15,676 FPAU
9 Kazo Kazo 1413 7,195 Kazo Diagnostic Medical Center
10 Rwampara Nyeihanga 662 3,030 Wilfam Medical Center
11 Mbarara Municipality Ruharo 1,658 7,794 Ruharo Mission hospital
12 Nyabushozi Rushere 1,002 4,988 Rushere Community Hospital
13 Nyabushozi Rushere 1,002 4,988 St. Michael Medicare Centre
14 Mbarara Municipality Ruti 1,189 4,824 Ruti Peoples Clinic
15 Isingiro Mabona 994 4,619 Clinic Africa
TOTAL OBA population 102,785
15 selected parishes by PPS from 225 non-OBA parishes in greater Mbarara district
+------------------------------------------------+
district sub-county parish parish~pop
------------------------------------------------
MBARARA KASHUMBA KASHUMBA 8338
MBARARA KASHUMBA KIGARAGARA 5927
MBARARA BISHESHE NYAKATOKYE 5805
MBARARA KICUZI KANYWAMBOGO 2532
MBARARA KIKYENKYE KEIHANGARA 7896
------------------------------------------------
MBARARA NYAMAREBE KYENGANDO 6976
MBARARA NYAKITUNDA NYAKARAMBI 4358
MBARARA BUBAARE RUGARAMA 3390
MBARARA BUREMBA KIJOOHA 4838
MBARARA KANONI ENGARI 5427
------------------------------------------------
MBARARA KAZO RWAMURANGA 2533
MBARARA SANGA RWABARATA 2673
MBARARA BUGAMBA KIBINGO 3787
MBARARA RUGANDO MIRAMA 3638
MBARARA RUGANDO NYABIKUNGU 4988
Population: 73,796
Selected from a total non-OBA population : 971,800
If X i is the population in parish i then the probability of including the parish in the
sample is given by:
Xi
πi = n
X
where n is the number of parishes selected in the sample in that district and X is the
total number of persons in the 225 non-OBA parishes of Mbarara district.
11 purposively selected parishes from 170 parishes in Bushenyi district
32
+--------------------------------------------------------+
| district subcounty_name parish~me parish~p |
|--------------------------------------------------------|
| BUSHENYI KABWOHE-ITENDERO T.C KABWOHE 4628 |
| BUSHENYI SHUUKU KISHABYA 5901 |
| BUSHENYI KYEIZOBA KITWE 4506 |
| BUSHENYI KIGARAMA MABARE 6166 |
| BUSHENYI KYAMUHUNGA MASHONGA 8170 |
| BUSHENYI RYERU NDEKYE 4619 |
| BUSHENYI KABWOHE-ITENDERO T.C NYANGA 4332 |
| BUSHENYI MITOOMA RUSHOROZA 3684 |
| BUSHENYI BUSHENYI TC WARD I 6028 |
| BUSHENYI BUSHENYI TC WARD III 7592 |
| BUSHENYI BUSHENYI TC WARD IV 3899 |
Total population 59,525
Second Stage Selection

At the second stage, two enumeration areas (EAs) were selected with probability
proportional to parish size without replacement from each parish selected in the first
stage.
+-----------------------------------------------------------------+
| parish_name lc_name ea_hholds ea_pop |
|-----------------------------------------------------------------|
| KASHUMBA BURAMA 115 474 |
| KASHUMBA KASHUMBA 184 759 |
| KIGARAGARA KAMISHWA 157 799 |
| KIGARAGARA RWAMACUMU 66 336 |
| NYAKATOKYE RWEBIYENJE I 44 218 |
| NYAKATOKYE BIGYERA 47 233 |
| KANYWAMBOGO KABUHWEJU 67 308 |
| KANYWAMBOGO KISABO I 126 579 |
| KEIHANGARA NGANGO I 108 521 |
| KEIHANGARA KANYEGANYEGYE 72 347 |
| KYENGANDO RWENKUREJU I 89 388 |
| KYENGANDO KOBUHURA A. 76 332 |
| NYAKARAMBI OMUBUSHAMI 122 548 |
| NYAKARAMBI OMUKINIKA 140 629 |
| RUGARAMA NKAAKA 153 792 |
| RUGARAMA RUGARAMA I 187 968 |
| KIJOOHA MUSHAMBYA 136 690 |
| KIJOOHA BUREMBA 185 938 |
| ENGARI RUSHANGO 113 603 |
| ENGARI NYABUBARE II 75 400 |
| RWAMURANGA MIRAMA 152 852 |
| RWAMURANGA RWAMURANGA 126 706 |
| RWABARATA RWAMUHUKU 192 774 |
| RWABARATA RWONYO 139 560 |
| NGUGO/KIBINGO NTSINGWA I 65 327 |
| NGUGO/KIBINGO RUSHANJE 101 509 |
| MIRAMA RWEMIYENJE 72 355 |
| MIRAMA MIRAMA II 49 242 |
| NYABIKUNGU MIKAMBA 69 367 |
| NYABIKUNGU KABOBO 68 361 |
+-----------------------------------------------------------------+
POPULATION 16184
If X i is the population in enumeration area (EA) i then the probability of including the
EA in the sample is given by:
33
Xi
πi = n
X
where n is the number of EAs selected in the sample in that parish and X is the total
number of persons in the parish (all potential EAs).
Table: In second stage, two EAs selected by PPS from each of 15 OBA parishes in old
Mbarara district
| district parish LC name EA hhold ea_pop |
|------------------------------------------------------------------|
| MBARARA BUFUNDA MPIIRA STREET 194 853 |
| MBARARA BUFUNDA NYAKATEETE II 92 405 |
| MBARARA KAGONGO KAFUNDA 73 357 |
| MBARARA KAGONGO KASHAKA II 133 650 |
| MBARARA MABONA MABONA 71 334 |
|------------------------------------------------------------------|
| MBARARA MABONA KYAMUDIMA 84 390 |
| MBARARA KAMUSHOKO RWEMPOGO 146 794 |
| MBARARA KAMUSHOKO RWAMBABANA 98 533 |
| MBARARA RWENSHANKU RWENTURAGARA 169 841 |
| MBARARA RWENSHANKU RWENSHANKU 106 528 |
|------------------------------------------------------------------|
| MBARARA KABARE NSHOZI 52 198 |
| MBARARA KABARE KARUHAMA 99 376 |
| MBARARA KAKYERERE BWIZIBWERA TR. A 124 575 |
| MBARARA KAKYERERE RWANYAMAHEMBE 131 607 |
| MBARARA KAZO KAZO II 228 1161 |
|------------------------------------------------------------------|
| MBARARA KAZO KAZO I 195 993 |
| MBARARA KAKOBA KISENYI 'B' 353 1405 |
| MBARARA KAKOBA LUGAZI ‘A’ 549 2186 |
| MBARARA KAMUKUZI KAKIIKA 'B' 603 2315 |
| MBARARA KAMUKUZI KASHANYALAZI 286 1098 |
|------------------------------------------------------------------|
| MBARARA RUHARO NKOKONJERU 'A' 309 1453 |
| MBARARA RUHARO KIYANJA 396 1862 |
| MBARARA KATETE KATETE CENTRAL 'A' 251 1106 |
| MBARARA KATETE NYAMITANGA 'A' 165 727 |
| MBARARA RUTI KAFUNDA 99 402 |
|------------------------------------------------------------------|
| MBARARA RUTI KATEERA 'A' 147 596 |
| MBARARA RUSHERE RUSHERE T/C 'A' 252 1254 |
| MBARARA RUSHERE RUSHERE T/C 'B' 172 856 |
| MBARARA NYEIHANGA NYEIHANGA 40 183 |
| MBARARA NYEIHANGA RWABAJOJO 59 270 |
POPULATION 22922
34
Table: In second stage, 22 EAs selected by PPS from 11 Bushenyi parishes with private
clinics
+--------------------------------------------------------------+
| district parish~me lc_name ea_hho~s ea_size |
|--------------------------------------------------------------|
| BUSHENYI NDEKYE RYERU I 142 638 |
| BUSHENYI NDEKYE RYERU II 117 561 |
| BUSHENYI WARD I CENTRAL CELL 'A' 281 1348 |
| BUSHENYI WARD IV CELL C 372 1756 |
| BUSHENYI WARD III CELL B 'A' 217 982 |
|--------------------------------------------------------------|
| BUSHENYI KITWE KITWE 99 488 |
| BUSHENYI MASHONGA NYAKATEMBE 123 569 |
| BUSHENYI WARD I CENTRAL CELL 'B' 253 1213 |
| BUSHENYI KITWE RWENTUHA TC 215 1060 |
| BUSHENYI WARD III CELL B 'B' 484 2190 |
|--------------------------------------------------------------|
| BUSHENYI MASHONGA KAYANGA 118 546 |
| BUSHENYI WARD IV CELL D 338 1595 |
| BUSHENYI RUSHOROZA NYAKASHOJWA 67 359 |
| BUSHENYI RUSHOROZA MITOOMA TOWN 205 1099 |
| BUSHENYI MABARE NYAKAMBU 143 696 |
|--------------------------------------------------------------|
| BUSHENYI KISHABYA KISHABYA 90 465 |
| BUSHENYI KISHABYA KYENJOJO 75 388 |
| BUSHENYI NYANGA KIGIMBI 146 612 |
| BUSHENYI NYANGA KABWOHE TOWN B 451 1889 |
| BUSHENYI MABARE KATWE 59 287 |
|--------------------------------------------------------------|
| BUSHENYI KABWOHE KABWOHE TOWN A 406 1729 |
| BUSHENYI KABWOHE KAMWEZI 44 187 |
POPULATION 20181
Third Stage Selection

At the third stage, survey teams took a sample of households from each selected
villages and analogous municipal cells. Teams were to select a sample of 36 individuals
(2,960 respondents from 82 villages and cells) at random households in the village such
that we get a proportional number of persons in each of the five age groups in each
district, which are 15-19, 20-24, 25-29, 30-35, and 36-49. This is done by first randomly
selecting a household from an enumerated list of all households in the village or cell. At
each selected household, all available The head of household or representative
completes the household census and asset modules with a survey team member. Then
one individual between 15-49 years of age is selected at random from the household to
complete the rest of the survey. In each village, persons in all age groups are selected
till there is a proportional number in each age group.
Age groups: 15-24 25-34 35-49

Numbers per group: 17 10 9
IN EACH VILLAGE INTERVIEW 36: totals
Village A males 9 5 4 18
females 8 5 5 18
Village B males 8 5 5 18
females 9 5 4 18
35
After the selection of the sample, it is useful to have a table for each district showing the
number of parishes in the population, number in the sample, number of EA/villages in
selected parishes and the number of households in selected villages and the numbers
selected in the sample.
Population No. No. No. of No. of No. of Total EA

parishes parishes selected households selected population
in EAs in per arm households^
sample parishes
OBA 119,824 15 15* 30 5,107 1080 22,922
parishes
Mbarara 968,532 225 15 30 3,473 1080 16,184
non-OBA
Bushenyi 731,392 170 11* 22 4,341 792 20,181
parishes
Total 1,819,748 410 41 82 12,921 2952 59,287
*purposively sampled (probability of selection =1)
^36 households per EA village were planned for in the survey
36
2006 2006 2007 2007
OBA non- OBA non-
OBA OBA
Respondent characteristics (independent variables)
Sample size 941 1669 1014 1639
Percent female 62.4% 56.2% 50.6% 48.4%
Mean age or age categories 30.5 31.7 29.6 29.9
Presence of health facility in community 34% 53% 34% 53%
Wealth index (from 7 common household items)
1. Low 32% 41% 26% 34%
2. Moderately low 24% 24% 23% 27%
3. Moderately high 23% 21% 22% 22%
4. High 21% 15% 24% 17%
Education
1. No education 9% 16% 8% 11%
2. Some primary 33% 36% 31% 35%
3. Completed primary 13% 8% 23% 21%
4. Some secondary 23% 19% 28% 22%
5. Completed secondary 22% 22% 11% 11%
Sex behavior
Unprotected sex with any partner 17% 15% 7% 8%
> having more than 1 partner 29% 23% 30% 24%
Outcomes of interest (dependent variables)
Heard about the OBA voucher 24% 20% 57% 48%
Seen the OBA voucher 1% 1% 12% 6%
Recognize at least 1 STI symptom (0-7 signs) 72% 68% 78% 78%
Reported 2+ STI symptoms past 6 months 58% 57% 55% 54%
Sought treatment for STI symptoms 31% 23% 36% 35%
STI treatment in private sector 64% 57% 50% 52%
Recent syphilis infection (VDRL assay) 6.3 6.4 6.0 3.9
37
38
APPE DIX 4: Study Design and Cross Over Concerns
The OBA impact evaluation has a quasi-experimental design in which intervention and
control communities were surveyed the first month of the program and 16 months after
program launch. Control communities allow for a same-time comparison between areas
treated by the voucher and areas not treated by voucher but otherwise alike to the
treatment group. The baseline survey was carried out in 82 villages and urban cells in
July and August 2006 and the follow-up survey was conducted in October and
November 2007 in the same communities and same sample size but with different
respondents. The sampling frame is explained in greater detail in Appendix 3.
The original selection of controls was made so as measure health status in areas without
contracted clinics (selected from the old Mbarara district) and areas that had non-
contracted private clinics (selected parishes in neighboring Bushenyi district). No other
factors were taken into consideration in parish selection. As with any control group,
there is the potential that populations in the control areas differ from the intervention
population on unobserved characteristics that affect the outcomes of interest.
Figure: A map of the region highlights the treatment and control areas of the evaluation
(surveyed parishes – Bushenyi – and villages – greater Mbarara – are colored in blue)
There are two important forms of bias to consider when designing the study and
analyzing the data: selection bias and information bias. Selection bias is error in
selecting the type of people chosen to participate in the study. For selection bias to
occur, the criteria for inclusion or exclusion must be related to the exposure or outcome
39
of interest. Information bias occurs when information is collected wrongly – more
specifically when information is collected differently from the groups under comparison.
On review of the data, there is evidence of selection bias but no significant information
bias. Cross-over was significantly greater than anticipated in the original sampling
frame. There is evidence that respondents from outside intervention areas sought
treatment in towns and villages that contained OBA clinics. There are several possible
explanations.
• The subcounties that did not contain OBA facilities may have had a higher
disease burden.
• The subcounties that did not contain OBA facilities may have had poorer patients
who found value in the subsidized service.
• Patients in the subcounties that did not contain OBA facilities were more
comfortable in the anonymity of seeking care at a facility far from home.
The available evidence, although limited, suggests that patients were seeking care far
from home locations possibly to avoid recognition. In the baseline survey, respondent
population in parishes without a contracted facility had slightly lower syphilis prevalence
(combined TPHA and VDRL) than the respondent population in OBA parishes; parishes
are the administrative unit immediately smaller than a subcounty. Although our sampling
frame was not designed to take representative samples at subcounty level, it does not
appear that disease burdens were higher in non-OBA areas. As for the second
possibility that patients from non-OBA areas were more responsive to the voucher
subsidy, it is not likely that the poor –those patients who would be most price sensitive -
would have the means to afford transport to a private facility outside their home
subcounty. The most reasonable conclusion is that patients sought STI treatment at
OBA facilities for reasons other than economic or epidemiologic – mostly likely out of a
concern of being recognized at a facility seeking treatment of STIs.
The strongest evidence come the claims data. A review of nearly 15,000 claims records
from July 2006 to April 2008 indicates that 64% of patients live in subcounties without a
contracted clinic. The fact that the majority of patients sought services outside their
resident subcounty underscores their mobility and suggests that the relatively small
contracted facilities in the OBA program have catchment areas that reach across
neighboring administrative areas.
As a result of the unanticipated magnitude of respondent cross over, analytic

comparisons between treatment and control areas in the same year become difficult. In
randomized trials with patient level follow-up an intent-to-treat analysis could be used to
address the crossover. In this paired cross-sectional design, the “control” status is
dropped and outcomes are analyzed in a simple before-after comparison of the same
villages surveyed in 2006 and 2007. Causal interpretation is tenuous given the lack of
contemporaneous controls; the intervening 16 months could have introduced other
reasons for change observed in the follow-up survey. However, the common exposure
to OBA focuses the evaluation on a comparison between years rather than determining
impact in specific administrative areas within a single year.
There is an important lesson on design to come from this evaluation. STI treatment
catchment areas are larger than expected, probably enlarged by the extensive marketing
and possibly stigma associated with being recognized at a near-by clinic.
40
41
APPE DIX 5: General Health Care Utilization
Asking respondents about general healthcare utilization gives some insight into facility
preference and presence. Facilities with higher utilization are likely experiencing the
benefits of patient preference and proximity. In both surveys, respondents were asked
about their use of health facilities for general healthcare in the past six months.
Healthcare utilization of surveyed households in 2006 and 2007
YEAR
Characteristic 2006 Number 2007 Number Significantly different?
Had any illness past 6
months
Yes 70% 1830 52% 1325
No 30% 768 48% 1209
2
Pearson χ 187.4,
100% 2598 100% 2534 p<0.001
Sought health service or

product past 6 months
Yes 85% 1552 79% 1042
No 15% 278 21% 283
2
100% 1830 100% 1325 Pearson χ 19.9, p<0.001
Type of healthcare
provider visited past 6
months
None
2
Traditional healer 13% 229 12% 156 Pearson χ 0.49, p=0.48
2
Drug shop 7% 122 4% 49 Pearson χ 14.5, p<0.001
2
Private for profit clinic 51% 934 36% 491 Pearson χ 19.9, p<0.001
2
Private not-for-profit clinic 5% 91 7% 92 Pearson χ 5.3, p=0.022
2
Private for-profit hospital 8% 153 5% 61 Pearson χ 69.1, p<0.001
2
Pearson χ 103.5,
Government clinic 21% 389 38% 513 p<0.001
2
Government hospital 31% 568 19% 253 Pearson χ 59.4, p<0.001
2
Mission hospital 7% 125 4% 58 Pearson χ 19.9, p<0.001
2
Other provider 2% 36 1% 9 Pearson χ 9.1, p=0.003
TOTAL
Provider type for STI

treatment
Private facilities 40% 614 30% 320
Govt facilities 60% 918 70% 746 Pearson χ2 27.6,
p<0.001
Barriers to healthcare
Women’s reasons for not seeking 2006 2007 Significant difference
general healthcare among female between 2006 and
respondents in 2006 and 2007 2007?
2
Lack of money 81% 71% Pearson χ 25.7, p<0.01
2
Distance to provider 45% 41% Pearson χ 3.6, p=0.06
2
Concern no drugs available 41% 38% Pearson χ 1.7, p=0.19
2
Transport to clinic 36% 32% Pearson χ 3.0, p=0.08
2
Concern no female provider available 25% 23% Pearson χ 1.1, p=0.28
2
Get permission 8% 14% Pearson χ 17.8, p<0.01
42
2
Fear of going alone to clinic 6% 12% Pearson χ 20.2, p<0.01
The most common reason for not seeking healthcare in both years was “lack of money”
followed by “distance to provider”. There were significant differences between survey
years when respondents were asked whether “lack of money”, “getting permission”, and
“fear of going alone to provider” kept the respondents from seeking healthcare. Four
other reasons to not seeking healthcare remained unchanged statistically between both
survey years. In both years, output-based aid (OBA) subsidies address the major
reason for not seeking healthcare – “lack of money”.
Reasons a respondent may not seek healthcare (by gender) in 2007

Percentages of respondents who consider the following factors a ‘big problem” when
seeking medical care for a personal illness. This table includes all respondents who
answered the question including those who recently had sought healthcare for any
ailment.
GENDER
Numbe
Healthcare barrier Males r Females Number
Getting money needed for treatment 60% 767 71% 884
The distance to the health clinic 32% 405 40% 502
Concern that there may be no drugs available 38% 403 38% 469
Having to take transport 25% 321 32% 398
Concern that there may not be any health
provider 20% 247 22% 275
Concern that there may not be a provider of
same sex 8% 106 9% 112
Getting permission to go 3% 41 14% 171
Not wanting to go alone 9% 107 12% 148
Among respondents of both genders, not having money for treatment was the most
frequent reason for not seeking healthcare. Distance to health facilities and concern
about drug availability were the second and third most common concerns.
In the 2007 survey, general healthcare utilization in the combined districts of Mbarara,
Ibanda, Isingiro, Kiruhura and Bushenyi districts suggest a pattern of reliance on private
out-patient clinics and government in-patient hospitals with clear gender differences in
utilization. Male respondents visit drug shops and private clinics more frequently than
female respondents (drug shops: 10% men versus 7% women; private clinics: 21% men
versus 15% women), while female respondents frequent government hospitals in higher
numbers than male respondents (20% women versus 14% men). These divergent
patterns are likely a result of women likely seeking inpatient care for deliveries.
43
Healthcare utilization of surveyed households by gender in 2007
GENDER TOTAL
POPULATION
Perce
Characteristic Males Number Females Number nt Number
Had any illness past 6
months
Yes 48.4 619 56.3 706 47.7 1209
No 51.6 659 43.7 548 52.3 1325
100.0 1278 100.0 1254 100.0 2534
Sought health service or

product past 6 months
Yes 40.6 523 48.1 607 44.3 1130
No 59.4 765 51.9 654 55.7 1421
100.0 1288 100.0 1261 100.0 2551
Respondents were asked about general healthcare utilization in the past six
months. The questions provide a wide perspective on respondents’ healthcare
seeking behaviors. The majority of respondents (52 percent) had a self-
described illness or health complaint in the preceding six months. The majority
of those respondents (80 percent) sought some form of healthcare service or
product for their health complaint.
Healthcare utilization of surveyed households by gender in 2007

GENDER TOTAL
POPULATION
Type of healthcare
provider visited in past 6
months
None 18% 117 14% 109 16% 226
Traditional healer 1% 7 1% 7 1% 14
Drug shop 10% 66 7% 51 8% 117
Private for profit clinic 21% 135 15% 111 17% 246
Private not-for-profit clinic 4% 24 2% 14 3% 38
Private for-profit hospital 1.7 11 2% 15 2% 26
Government clinic 27% 178 35% 262 31% 440
Government hospital 14% 93 20% 149 17% 242
Mission hospital 4% 25 4% 33 4% 58
Other provider 1% 3 1% 6 1% 9
TOTAL 100% 659 100% 757 100%s 1416
Among those who sought some form of health service or product, 37 percent of
respondents sought care at private facilities. Government clinics received the two
highest frequencies of patient visits (38 percent) followed by private clinics (21 percent).
The most common form of service at both types of clinics is outpatient care. Outpatient
care is common for treatment of fevers – the most common complaint among healthcare
seekers. The third most frequented provider was government hospitals (17 percent). It
44
is likely that patients with severe conditions, including costly in-patient care, go to
government hospitals where the service is more affordable than private hospitals, which
are few and costly, or private clinics which lack the capacity to provide in-patient care.
Broadly classifying self-reported use of general healthcare into private and public
categories shows more frequent use of public providers compared to private providers in
the six months preceding the 2007 follow-up survey. “Private sector” in this question
includes drug shops, private-not-for-profit clinics, private for profit clinics, and private
hospitals. “Public sector” includes government clinics, government hospitals, and
mission hospitals. Not included in either category are traditional healers. Anecdotal
evidence suggests that use of traditional healers may be underreported.
The table below indicates that respondents were overwhelmingly preoccupied by fevers
during visits to the most frequented provider, which bears out given the frequency and
severity of malarial infections in the region. On the list of common conditions, no other
health complaint has as frequent a recurrence in the population.
Healthcare complaints by gender

Among respondents who reported seeking healthcare, they were asked for the primary
complaint at the most recent healthcare visit.
GENDER TOTAL
Females Perce
Health complaint Males % Number % Number nt Number
Antenatal care or delivery 1% 2 9% 58 5% 60
Family planning 0 0 2% 14 1% 14
Genital sores/discharge 11% 57 8% 54 9% 111
Severe cough 6% 31 6% 36 6% 67
Fevers 61% 334 49% 317 54% 651
Diarrhoea / Gastrointestinal 4% 19 6% 40 5% 59
Health information/advice 4% 21 5% 35 5% 56
VCT for HIV 2% 8 2% 15 2% 23
Eye care 1% 2 1% 3 1% 5
Dermatitis 1% 5 1% 6 1% 17
Cardiac complaints 1% 3 1% 5 1% 11
Headache 1% 6 2% 11 1% 8
Other 10% 56 9% 60 10% 116
TOTAL 100% 544 100% 654 100% 1198
45

Evaluation of The Output Based Approach in Uganda: Impact of Contracted Facilities and Social Marketed Vouchers On Knowledge, Utilization, and Prevalence of Sexually Transmitted Infections 2006-07

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Evaluation of The Output Based Approach in Uganda: Impact of Contracted Facilities and Social Marketed Vouchers On Knowledge, Utilization, and Prevalence of Sexually Transmitted Infections 2006-07

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EVALUATION OF OUTPUT-BASED AID (OBA) IN

IMPACT OF CONTRACTED FACILITIES AND SOCIAL

Bushenyi, Ibanda, Isingiro, Kiruhura, and Mbarara Districts

Output-based Aid Uganda – Follow-up Survey Report 1

THE KFW DEVELOPMENT BANK WITH

SUPPLEMENTAL SUPPORT OF THE BOREN FELLOWSHIP AND

THE BIXBY PROGRAM IN POPULATION, FAMILY PLANNING, AND

THE UNIVERSITY OF CALIFORNIA, BERKELEY

Output-based Aid Uganda – Follow-up Survey Report 2

LIST OF ABBREVIATIONS ................................................................................................... 4

Output-based Aid Uganda – Follow-up Survey Report 3

GPOBA Global Partnership on Output-based Aid

Output-based Aid Uganda – Follow-up Survey Report 4

Output-based Aid Uganda – Follow-up Survey Report 5

Output-based Aid Uganda – Follow-up Survey Report 6

Table 1.1: Background characteristics in 2006 and 2007 surveys

Output-based Aid Uganda – Follow-up Survey Report 7

Output-based Aid Uganda – Follow-up Survey Report 8

2.1 How well did respondents know about the voucher?

Awareness of OBA STIs voucher

2006 (%) Sample 2007 (%) Sample

Among those w/ reactive

Output-based Aid Uganda – Follow-up Survey Report 10

Media and patient claims

2.2 How well did respondents know about symptoms?

Output-based Aid Uganda – Follow-up Survey Report 11

2006 (%) Sample 2007 (%) Sample T-test p-value

Figure: Number of signs and symptoms of STIs recognized by respondents

To test whether the observed improvements in knowledge may be due to common

Output-based Aid Uganda – Follow-up Survey Report 12

Term Coefficient rates 95% confidence

Output-based Aid Uganda – Follow-up Survey Report 13

1. Who reports having STI symptoms?

3.1 Who reports having STI symptoms?

In past 6 months have you or 2006 2007

Proportion of respondents 2006 2007

Output-based Aid Uganda – Follow-up Survey Report 14

Women 62% 51%

Proportion of respondents 2006 & 2007 Combined

Women 57% 43%

Output-based Aid Uganda – Follow-up Survey Report 15

3.2 Of those reporting STI symptoms, who seeks treatment?

Of respondents with STI symptoms, 2006 2007

Provider type for STI treatment

Satisfaction with STI Public Private

Output-based Aid Uganda – Follow-up Survey Report 16

Reasons for not seeking STI 2006 2007

Women’s reasons for no treatment

Choice of provider among those who

Output-based Aid Uganda – Follow-up Survey Report 17

3.3 How many patients traveled from subcounties without clinics?

3.4 Poverty rate among voucher patients

Output-based Aid Uganda – Follow-up Survey Report 18

Total Subcounties with Subcounties w/o

3.5 How competitive was voucher utilization?

Herfindahl-Hirschman index (HHI) is a measure of market concentration. Here, it measures

monthly voucher sales

Herfindahl-hirschman index Voucher sales

Output-based Aid Uganda – Follow-up Survey Report 19

Output-based Aid Uganda – Follow-up Survey Report 20

OBA intervention is the combination of radio health education

Patients visit OBA Vouchers shared

Prevalence of syphilis 2006 2007 Significance test