DEMAND SIDE FINANCING MATERNAL HEALTH VOUCHER SCHEME in Bangladesh

1. DEMAND SIDE FINANCING MATERNAL HEALTH VOUCHER SCHEME in Bangladesh

2. 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

3. 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. 2000 [$25] and gift bags if women deliver with skilled birth attendant at home or in facility, and transport stipend Tk. 500 [$ 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

4. 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.

5. Empowered voucher holders: Have a choice of service provider Client in labor Home based delivery Facility delivery SBA Upazila Health Complex/District Hosp/MCWC Comm. Clinic NGO/Private Clinic Family Welfare Center Union Sub-Center

6. Governance structures

7. Budget in HPNSDP 2011-16 earmarked for DSF

8. 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 2013. Results pending. • In 2013, an In-depth study is done. Results disseminated.

9. Effectiveness

10. ANC1 (%) of DSF vs National (BDHS) Source: DSF project office

11. ANC in DSF Upazila vs Control Upazila Source: Economic evaluation, 2010

12. Safe delivery (%) of DSF vs National (BDHS) Source: DSF project office

13. Percentages of deliveries with a skilled provider Source: Economic evaluation, 2010

14. C-section (%) of DSF vs National (BDHS) Source: DSF project office

15. PNC (%) of DSF vs National (BDHS) Source: DSF project office

16. Equity

17. 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.

18. Where does the DSF support ($48) go for a normal delivery?

19. Where does the DSF support ($145) go for complicated cases (except vacuum)?

20. 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?

21. Thank you