DEMAND SIDE FINANCING MATERNAL HEALTH VOUCHER SCHEME in Bangladesh 1
Maternal health in Bangladesh Context 149.8m total population (Rural 73%) 545 Sub-districts 31.5% Population below poverty line 71% deliveries take place at home 29% Institutional delivery 32% Skilled attended delivery 194 MMR (BMMS 2010) 2.15 TFR (BBS 2009) Demand-side barriers to access Poverty Illiteracy Geographical accessibility Lack of information about health services High direct and indirect costs especially transportation Intra-household expenditure preferences Socio-cultural norms 2
DSF program overview: incentives for both demand and supply side Aims to rapidly increase utilization of maternal health (MH) services via: Vouchers for free antenatal (ANC), delivery, emergency referral, and postnatal care (PNC), and laboratory tests. Cash transfers Tk [$25] and gift bags if women deliver with skilled birth attendant at home or in facility, and transport stipend Tk. 500 [$ 6.25]. Emergency referral transport is also available. Cash incentives for providers/field workers for registering women and providing MH services “Seed fund” for facilities 3
Project Beneficiaries: the poor and vulnerable women In general, pregnant women are eligible to receive free voucher under the scheme if they fulfil the following criteria: First and second pregnancy Resident in the respective Upazila Are functionally landless i.e. owning less than 0.15 acre of land. Have extremely low or irregular income - households earning less than Taka 2500 [US$ 31.25] per month (proposed to be increased to 3100 [US$38.75]) Lack of productive assets.
Empowered voucher holders: Have a choice of service provider Home based delivery Facility delivery SBA Upazila Health Complex/Distr ict Hosp/MCWC Union Sub- Center Comm. Clinic NGO/Pri vate Clinic Family Welfare Center Client in labor 5
Governance structures
7 Financial Year In million BDT US$ BDT US$ BDT US$ & BDT US$ Total earmarked allocation for DSF ( ) BDT US$ (0.7%) Total Health Sector Budget ( ) BDT US$ 7.7 billion Expanded DSF is sustainable at <1% of health sector budget Budget in HPNSDP earmarked for DSF
Evaluations on DSF Maternal Health Voucher Scheme In 2008, a rapid assessment of DSF with support of GTZ and MOHFW found maternal health service utilization had increased substantially in pilot sub districts. Report advocated scale up. In 2010, USA-based Abt Associates with GTZ and MOHFW support assessed economic evaluation of expanded program. Study found that DSF had a strong positive effect on the use of maternal health services in expanded program. In 2011, Population Council began a quasi-experimental evaluation of DSF. Baseline in 2011 was collected utilization and cost data from 11 DSF and 11 non-DSF sub districts. End line survey completed May Results pending. In 2013, an In-depth study is done. Results disseminated.
Effectiveness 9
ANC1 (%) of DSF vs National (BDHS) Source: DSF project office 10
ANC in DSF Upazila vs Control Upazila Source: Economic evaluation,
Safe delivery (%) of DSF vs National (BDHS) Source: DSF project office 12
Percentages of deliveries with a skilled provider Source: Economic evaluation,
C-section (%) of DSF vs National (BDHS) Source: DSF project office 14
PNC (%) of DSF vs National (BDHS) Source: DSF project office 15
Equity 16
Project Beneficiaries In general, pregnant women are eligible to receive free voucher under the scheme if they fulfil the following criteria: First and second pregnancy Resident in the respective Upazila Are functionally landless i.e. owning less than 0.15 acre of land. Have extremely low or irregular income - households earning less than Taka 2500 [US$ 31.25] per month (proposed to be increased to 3100 [US$38.75]) Lack of productive assets.
Where does the DSF support ($48) go for a normal delivery?
Where does the DSF support ($145) go for complicated cases (except vacuum)?
Things to ponder Is DSF effective? Is DSF able to address equity? Does it contribute in achieving MDG target of MMR? Should we recommend for scaling up? 20
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